Bartonelose: doença de importância para a saúde pública envolvendo a tríade homem-ambiente-animal / Bartonellosis: disease of importance for public health involving the man-environment-animal triad / Bartonelosis: enfermedad de importancia para la salud pública que involucra la triada hombre-ambiente-animal

A relação hospedeiro-parasita é caracterizada como uma interação alelobiótica construída por meio de processos evolutivo-adaptativos com hospedeiros assintomáticos. No ambiente silvestre é notório o equilíbrio desta relação, porém quando há intervenção antropogênica um ciclo enzoótico pode se estabelecer proporcionando o surgimento de enfermidades emergentes ou reemergentes. Dentre estes agentes etiológicos, a Bartonella spp. é um bacilo gram-negativo da classe Proteobacteria que apresentam tropismo por eritrócitos e células endoteliais, com infecção já descrita em animais das Ordens: Rodentia, Lagomorpha, Carnivora, Artiodactyla, Eulipotyphla e Chiroptera. A infecção pela bactéria pode estar associada à linfadenite, endocardite, angiomatose bacilar e peliose hepática em humanos. Treze espécies de Bartonella spp. são tidas como zoonóticas. O objetivo desta revisão está em apontar para a comunidade científica a bartonelose como uma doença de notificação obrigatória, assim como, os possíveis hospedeiros em animais domésticos e silvestres e sua etiopatogenia.(AU)

The host-parasite relationship is characterized as an allelobiotic interaction built through evolutionary-adaptive processes with asymptomatic hosts. In the wild environment, the balance of this relationship is notorious, but when there is anthropogenic intervention, an enzootic cycle can be established, providing the emergence of emerging or reemerging diseases. Among these etiologic agents, Bartonella spp. is a gram-negative bacillus of the Proteobacteria class that presents tropism for erythrocytes and endothelial cells, with infection already described in animals of the Orders: Rodentia, Lagomorpha, Carnivora, Artiodactyla, Eulipotyphla and Chiroptera. Infection by the bacterium may be associated with lymphadenitis, endocarditis, bacillary angiomatosis and peliosis hepatica in humans. Thirteen species of Bartonella spp. are considered zoonotic. The objective of this review is to point out to the scientific community bartonellosis as a notifiable disease, as well as the possible hosts in domestic and wild animals and their etiopathogenesis.(AU)

La relación hospedador-parásito se caracteriza por ser una interacción alelobiótica construida mediante procesos evolutivo-adaptativos con hospedadores asintomáticos. En el medio silvestre, el equilibrio de esta relación es notorio, pero cuando hay intervención antropogénica, puede establecerse un ciclo enzoótico, propiciando la aparición de enfermedades emergentes o reemergentes. Entre estos agentes etiológicos, Bartonella spp. es un bacilo gramnegativo de la clase Proteobacteria que presenta tropismo por eritrocitos y células endoteliales, con infección ya descrita en animales de los Órdenes: Rodentia, Lagomorpha, Carnivora, Artiodactyla, Eulipotyphla y Chiroptera. La infección por la bacteria puede estar asociada a linfadenitis, endocarditis, angiomatosis bacilar y peliosis hepática en humanos. Trece especies de Bartonella spp. se consideran zoonóticas. El objetivo de esta revisión es señalar a la comunidad científica la bartonelosis como enfermedad de declaración obligatoria, así como los posibles hospedadores en animales domésticos y salvajes y su etiopatogenia.(AU)

Prevalence of Bartonella species in shelter cats and their ectoparasites in southeastern Brazil / Prevalência de espécies de Bartonella em gatos de abrigos e seus ectoparasitas no Sudeste do Brasil

Abstract Feline Bartonella can be transmitted to humans through cat scratches or bites, and between cats, by the flea Ctenocephalides felis. The study was carried out in order to investigate the occurrence of Bartonella DNA in cats living in shelters and their ectoparasites and the relationship between the infection status of cats and ectoparasites they host. Bartonella DNA was detected in 47.8% of the cat blood samples, 18.3% of C. felis fleas, 13.3% of flea egg pools and 12.5% of lice pools. B. henselae and B. clarridgeiae DNA were detected in cat fleas, while B. henselae, B. clarridgeiae and B. koehlerae were found in blood samples from bacteremic cats. Cats infested by positive ectoparasites showed approximately twice the odds of being infected. Our results indicate that shelter cats have high prevalence of Bartonella species that are known to be human pathogens. This highlights the importance of controlling infestations by ectoparasites to avoid cat and human infection.

Resumo Algumas espécies de Bartonella têm os felinos como principais hospedeiros reservatórios. Tais patógenos são transmitidos ao homem por intermédio da arranhadura ou mordedura de gatos e entre os gatos, por meio da pulga Ctenocephalides felis. O objetivo deste estudo foi investigar a ocorrência de DNA de Bartonella spp. em gatos de abrigos e seus ectoparasitas e a relação entre o estado de infecção dos gatos e dos ectoparasitas albergados por estes. Material genético bacteriano foi detectado em 47,8% das amostras de sangue de gatos, 18,3% das pulgas C. felis, 13,3% dos "pools" de ovos de pulgas e 12,5% dos "pools" de piolhos. DNA de B. henselae e B. clarridgeiae foi detectado em pulgas, e B. henselae, B. clarridgeiae e B. koehlerae, em amostras de sangue de gatos. Gatos infestados por ectoparasitas que carreavam DNA de Bartonella spp. demonstraram aproximadamente o dobro de chance de estarem infectados. Esses resultados indicam que os gatos de abrigos têm alta prevalência de infecção por espécies de Bartonella, capazes de causar doenças no homem. E também destacam a importância do controle e prevenção da infestação por ectoparasitas, no intuito de prevenir a infecção em gatos e humanos.

Occurrence of Bartonella genotypes in bats and associated Streblidae flies from Maranhão state, northeastern Brazil / Ocorrência de genótipos de Bartonella em morcegos e moscas Streblidae no Estado do Maranhão, Nordeste do Brasil

Abstract Bartonella is a genus of emerging zoonotic bacteria that are mainly associated with mammalian erythrocytes and endothelial cells. Bats are natural reservoirs for a variety of important pathogens that impact human and animal health. Recent reports have highlighted the role of bats and bat flies in the maintenance of Bartonella. Here, we showed that none of the 29 bat DNA blood samples obtained from five bat species in São Luís Island, state of Maranhão, northeastern Brazil, were positive for Bartonella in qPCR assays targeting nuoG. On the other hand, three out of 15 DNA samples (20%) from flies in the family Streblidae were positive for Bartonella. The BLASTn results showed that the gltA and rpoB sequences shared identities ranging from 97.2% to 100%, with Bartonella sequences amplified from bats or bat flies from Costa Rica and Brazil. These findings were supported by phylogenetic analyses based on Bayesian inferences. The present study showed that Bartonella genotypes are present in bat flies, thus shedding some light on the distribution of bat fly-related Bartonella genotypes in South America.

Resumo Bartonella é um gênero de bactérias zoonóticas emergentes associadas principalmente a eritrócitos e células endoteliais de mamíferos. Morcegos são reservatórios naturais para uma variedade de patógenos importantes que afetam a saúde humana e animal. Além disso, estudos recentes destacaram o papel dos morcegos e de moscas associadas a morcegos na manutenção de Bartonella. No presente estudo, nenhuma das 29 amostras de DNA obtidas a partir do sangue de cinco espécies de morcegos amostrados na ilha de São Luís, estado do Maranhão, Nordeste do Brasil, foi positiva para Bartonella nos ensaios de qPCR direcionados ao gene nuoG. Por outro lado, três das 15 (20%) amostras de DNA de moscas da família Streblidae foram positivas para Bartonella. Os resultados do BLASTn mostraram que as sequências dos genes gltA e rpoB compartilharam identidade, variando de 97,2% a 100%, com as sequências de Bartonella amplificadas em morcegos ou moscas amostrados na Costa Rica ou Brasil. Tais resultados corroboraram as análises filogenéticas realizadas por Inferência Bayesiana. O presente estudo mostrou a ocorrência de Bartonella em moscas de morcegos, auxiliando a esclarecer a distribuição dos genótipos de Bartonella relacionadas a moscas Streblidae na América do Sul.

Prevalencia de Bartonella henselae en donantes de sangre y riesgo de transmisión sanguínea en Chile / Prevalence of Bartonella henselae in blood donors and risk of blood transmission in Chile

Resumen Introducción: Bartonella henselae es el agente causal de la enfermedad del arañazo del gato en personas inmunocompetentes y de la angiomatosis bacilar y peliosis hepatis en inmunocomprometidos. En Chile la prevalencia de anticuerpos contra B. henselae en niños y adolescentes sanos es de 13,3%, en personas con riesgo ocupacional 60,5% y en gatos 85,6%. No existen datos publicados respecto de la seroprevalencia en donantes de sangre en nuestro país, por lo que determinar si B. henselae se encuentra presente en la sangre de los donantes al momento de la donación es muy importante, ya que este microorganismo puede sobrevivir hasta 35 días en los eritrocitos almacenados en banco de sangre a 4 °C. Objetivo: Determinar la prevalencia de B. henselae en donantes de sangre. Metodología: Se analizaron 140 muestras de sangre de donantes, para detectar la presencia de B. henselae, utilizando la técnica de la reacción de polimerasa en cadena (RPC). Resultados: Se obtuvo 13,6% de los donantes de sangre con RPC positiva para la B. henselae. La secuencia de los fragmentos amplificados presentó una identidad por sobre 98% con respecto a secuencias de B. henselae de referencia. Conclusión: El riesgo de transmisión sanguínea debiera ser considerado en un país con alta seroprevalencia de infección por B. henselae.

Background: Bartonella henselae is the causal agent of cat scratch disease in immunocompetent persons and bacterial angiomatosis in immunocompromised patients. In Chile, the prevalence of antibodies against B. henselae in healthy children and adolescents is 13.3%, in persons with occupational risk 60.5%, and in cats 85.6%. There are no published data regarding the seroprevalence in blood donors in our country, so determining if B. henselae is present in the blood of donors at the time of donation is very important, since this microorganism can survive up to 35 days in the red blood cells stored in a blood bank at 4 °C. Objective: To determine the prevalence of B. henselae in blood donors. Methodology: 140 donor blood samples were analyzed to detect the presence of B. henselae, using the polymerase chain reaction technique. Results: 13.6% of the blood donors with positive polymerase chain reaction for B. henselae were obtained. The sequence of the amplified fragments showed an identity of over 98% with respect to B. henselae reference sequences. Conclusion: The risk of blood transmission is due to a country with high B. henselae infection.

Bartonella species pathogenic for humans infect pets, free-ranging wild mammals and their ectoparasites in the Caatinga biome, Northeastern Brazil: a serological and molecular study

ABSTRACT This study verified the occurrence of Bartonella spp. in dogs, cats, wild mammals and their ectoparasites in Petrolina and Lagoa Grande Counties, Pernambuco, located in a semi-arid region in Northeastern Brazil. Anti-Bartonella spp. antibodies were detected by indirect immunofluorescence assay (IFA) in 24.8% of dogs (27/109) and in 15% of cats (6/40). Bartonella sp. DNA was identified by PCR performed on DNA extracted from blood and ectoparasites using primers targeting Bartonella sp. gltA and ribC genes in 100% (9/9) of Pulex irritans from Cerdocyon thous, 57.4% (35/61) of P. irritans from dogs, 2.3% (1/43) of Ctenocephalides felis felis from dogs, 53.3% (24/45) of C. felis felis from cats, and 10% (1/10) of Polyplax spp. from Thrichomys apereoides. DNA sequencing identified Bartonella clarridgeiae and Bartonella henselae in C. felis felis from cats, Bartonella rochalimae in P. irritans from dog and C. thous, and Bartonella vinsoni berkhofii in P. irritans from dog.

Evidência sorológica de infecção por Bartonella spp., Coxiella burnetii e Hantavirus em profissionais de um abrigo de animais no município do Rio de Janeiro / Serological evidence of infection with Bartonella spp., Coxiella burnetii and Hantavirus in professional an animal shelter in the city of Rio de Janeiro

O risco de infecção por agentes zoonóticos é considerado maior em profissionais quemanuseiam animais. O crescente aumento de animais abandonados nos grandes centrosurbanos e o seu recolhimento em abrigos, cujas condições sanitárias e de infraestruturasão precárias aumentam o risco de transmissão de tais agentes não somente entre osanimais, mas também para os profissionais, determinando, assim, a ocorrência dezoonoses ocupacionais. Neste cenário, cinco funcionários de um abrigo de animais domunicípio do Rio de Janeiro morreram, após um surto de febre maculosa, e um inquéritosorológico realizado entre os profissionais desse abrigo e nos cães demonstrou queempregados e cães eram sororreativos com elevados títulos sorológicos. Diante doexposto e da necessidade de complementar a pesquisa sobre outros agentes zoonóticosque pudessem estar associados com doença ocupacional, foi realizado um estudo com oobjetivo de investigar a presença de anticorpos anti-Coxiella burnetii, anti-Bartonella,anti-Hantavirus em profissionais de um abrigo, como parte das medidas instituídas nocontexto da vigilância epidemiológica do Laboratório de Hantavirose e Rickettsioses doInstituto Oswaldo Cruz, onde o estudo foi realizado. O resultado da análise mostrou umasoroprevalência de 8,7 por cento (8/92) para febre Q, uma prevalência superior à comparada àsoutras taxas encontradas na população geral brasileira. A prevalência de anticorpos antiBartonellaspp. foi de 1,7 por cento (2/118), muito inferior se comparada às taxas observadas emoutros estudos, principalmente no Brasil onde as taxas são superiores a 30 por cento. Todas as118 amostras foram negativas para hantavirose. Apesar das limitações de um estudoretrospectivo utilizando dados secundários, o presente estudo alerta para a necessidade dese instituir medidas de precauções efetivas nos abrigos de animais para diminuir o riscoocupacional de infecções zoonóticas em profissionais que manuseiam animais...

The risk of zoonotic agents infection is considered higher in professionals who care foranimals. The increasing of abandoned animals in the big cities and your accommodationin shelters (with poor sanitary conditions and inadequate infrastructure) increase the riskof transmission of zoonotic agents not only in animals but also for professionals, thusdetermining the occurrence of occupational zoonoses. In this scenario, five employees ofan animal shelter in a city of Rio de Janeiro died after an outbreak of Rocky Mountainspotted fever, in which a serological survey in the animal shelter workers and dogsdemonstrated that employees and dogs were seroreactive with high titers. Given the aboveand the need for additional research on other zoonotic agents that might be associatedwith occupational disease, an study was conducted in order to investigate the presence ofanti-Coxiella burnetii, anti-Bartonella, anti-Hantavirus in professional na an animalshelter as part of the measures imposed in the contexto of epidemiological surveillanceof Hantavirus and Rickettsiosis Laboratory of the Oswaldo Cruz Institute, where the studywas conducted. The analisys showed a prevalence of 8.7 percent (8/92) for Q fever, a higherprevalence compared to the other rates found in the general Brasilian population. Theprevalence of antibodies anti-Bartonella spp. was 1.7 percent (2/118), much lower comparedto rates observed in other studies, particularly in Brazil where rates above 30 percent. All 118samples were negative for hantavirus. Despite the limitations of a retrospective studyusing secondary data, this study points to the need establish effective precautionmeansures in animal shelters to reduce occupational risk of zoonotic infections inprofessionals who care for animals...

Experiencias en la prevención y control de la enfermedad de Carrión en el Perú / Experiences in the prevention and control of Carrión's disease in Peru

La enfermedad de Carrión, enfermedad emblemática de la medicina peruana, ha sido descrita en la sierra de Ecuador, Colombia y valles interandinos del Perú. En la década de 1990, el fenómeno de El Niño fue asociado con incremento significativo del riesgo de enfermedad en Ancash, Cajamarca y Cusco. Justamente en Cusco en 1998 se produjo una importante epidemia de la fase aguda en diversas provincias andinas y la zona selvática. Posteriormente entre 2001 y 2005 la enfermedad se ha expandido o reactivado en diversas regiones como Ancash, Cajamarca, Amazonas, Piura, Cusco, La Libertad, Puno, Ayacucho. El 2004 se presentó un rebrote importante de la enfermedad en todo el Perú, reportándose más de 11 164 casos, por ello se aplicaron diversas estrategias de control basados en estudios de susceptibilidad de vectores, disminuyendo en forma significativa el número de casos.

Carrion’s disease, the iconic disease in Peruvian medicine has been found in the mountains of Ecuador, Colombia and the Andean valleys of Peru. In the 1990s, the phenomenon of El Niño was associated with significantly increased risk of disease in Ancash, Cajamarca and Cusco. In Cusco in 1998 there was an acute phase epidemic in various Andean provinces and the jungle area. Between 2001 and 2005 the disease has spread or reactivated in different regions such as Ancash, Cajamarca, Amazonas, Piura, Cusco, La Libertad, Puno, and Ayacucho. In 2004 a major outbreak of the disease in all of Peru was presented, reporting more than 11 164 cases, and therefore diverse strategies based vector susceptibility studies was applied, lowering significantly the number of cases.

Conocimientos, actitudes y prácticas sobre la enfermedad de Carrión en población rural de Ancash, Perú / Knowledge, attitudes, and practices about Carrión's disease in rural Ancash, Peru

OBJETIVO: Evaluar el conocimiento, las prácticas y las actitudes sobre la enfermedad de Carrión (bartonelosis) en poblaciones rurales con antecedentes de brotes epidémicos. MÉTODOS: Estudio transversal realizado en las poblaciones de Huaripampa, Orcosh y Opayaco (Ancash, Perú) durante el mes de julio del 2010, utilizando una encuesta para evaluar el conocimiento, las prácticas y las actitudes sobre la enfermedad de Carrión. Se entrevistó solo a mayores de 18 años que tuviesen una antigüedad mínima de un año residiendo en esos poblados. RESULTADOS: Se realizaron encuestas a un total de 276 pobladores, de los cuales 36,6% fueron hombres y 72,5% no había oído hablar de la enfermedad de Carrión. Entre los que la conocían, la mayoría (38,7%) indicó que se contagia mediante picaduras, mientras que 26% manifestó no conocer la forma de contagio. Con respecto a las acciones que deberían tomarse en caso de presentar la enfermedad de Carrión, 69,3% de los encuestados refirieron que acudirían a un centro de salud y más de la mitad informó haber recomendado prácticas preventivas a familiares o conocidos en el pasado. CONCLUSIONES: A pesar de tratarse de comunidades históricamente afectadas por la enfermedad de Carrión, los pobladores de estas tres comunidades no mostraron un nivel adecuado de conocimientos, actitudes o prácticas para su prevención. En vista de ello, y teniendo en cuenta que este padecimiento ha presentado brotes cíclicos, se hace perentorio diseñar e implementar un programa que eduque a los habitantes de estos poblados -poniendo el foco en el papel de los usos y costumbres- sobre cómo prevenir la enfermedad de Carrión, así como el resto de las principales enfermedades endémicas de la región.

OBJECTIVE: To assess knowledge, attitudes, and practices about Carrión's disease (bartonellosis) in rural communities with a history of epidemic outbreaks. METHODS: A cross-sectional survey study was conducted in the communities of Huaripampa, Orcosh, and Opayaco (Ancash, Peru) in July 2010, to assess knowledge, attitudes, and practices about Carrión's disease. Interviewees were aged >18 years and had resided in the community for at least one year. RESULTS: A total of 276 residents were surveyed; 36.6% were men, and 72.5% had not heard of Carrión's disease. Of those familiar with it, most (38.7%) said that it spreads through bites, and 26% did not know how it spreads. Regarding actions to take if Carrión's disease develops, 69.3% of respondents said they would go to a health center and over half reported having recommended preventive practices to relatives or acquaintances in the past. CONCLUSIONS: Even though these three communities have a history of Carrión's disease, their inhabitants did not demonstrate adequate knowledge, attitudes, or practices for preventing it. In view of this, and given that this illness has cyclical outbreaks, it is imperative to design and implement a program to educate residents of these communities-focusing on the role of habits and customs-about how to prevent Carrión's disease, as well as the region's other main endemic diseases.

Respuesta inmune en pacientes con bartonelosis humana en un área endémica de Perú / Immune response in patients with human Bartonella infection in an endemic area of Peru

Se llevó a cabo un estudio piloto en una zona de bartonelosis endémica humana en el Perú, con la captación de pacientes en fase aguda y crónica para el mejor conocimiento de su respuesta inmunitaria.

Cytokines and T-Lymphocute count in patients in the acute and chronic phases of Bartonella bacilliformis infection in an endemic area in peru: a pilot study / Citoquinas y recuento de Linfocitos T en pacientes en fase aguda y crónica de infección por Bartonella bacilliformis, en una área endémica del Perú: estudio piloto

Human Bartonellosis has an acute phase characterized by fever and hemolytic anemia, and a chronic phase with bacillary angiomatosis-like lesions. This cross-sectional pilot study evaluated the immunology patterns using pre- and post-treatment samples in patients with Human Bartonellosis. Patients between five and 60 years of age, from endemic areas in Peru, in the acute or chronic phases were included. In patients in the acute phase of Bartonellosis a state of immune peripheral tolerance should be established for persistence of the infection. Our findings were that elevation of the anti-inflammatory cytokine IL-10 and numeric abnormalities of CD4+ and CD8+ T-Lymphocyte counts correlated significantly with an unfavorable immune state. During the chronic phase, the elevated levels of IFN-γ and IL-4 observed in our series correlated with previous findings of endothelial invasion of B. henselae in animal models.

La Bartonelosis Humana, tiene una fase aguda caracterizada por fiebre y anemia hemolítica, así como una fase crónica con lesiones semejantes a angiomatosis bacilar. En un estudio transversal piloto los patrones inmunológicos en pacientes con Bartonelosis Humana fueron estudiados mediante muestras pre y post tratamiento. Pacientes entre 5 y 60 años en fase aguda y crónica fueron incluidos en área endémica del Perú. En aquellos pacientes con fase aguda, una fase de tolerancia inmunológica periférica es necesaria para la persistencia de la infección. Los hallazgos de significativa elevación de citoquina anti-inflamatoria (IL-10) y anormalidades numéricas en el recuentos de Linfocitos T CD4+ y CD8+ correlacionan con un estado inmune que favorece la infección. Durante la fase crónica, elevados niveles de INF-γ y IL-4 observados en la serie de pacientes correlacionan con previos hallazgos en modelos animales que favorecen la invasión del endotelio por B. henselae.

Human bartonellosis: seroepidemiological and clinical features with an emphasis on data from Brazil - A review

Bartonellae are fastidious Gram-negative bacteria that are widespread in nature with several animal reservoirs (mainly cats, dogs, and rodents) and insect vectors (mainly fleas, sandflies, and human lice). Thirteen species or subspecies of Bartonella have been recognized as agents causing human disease, including B. bacilliformis, B. quintana, B. vinsonii berkhoffii, B. henselae, B. elizabethae, B. grahamii, B. washoensis, B. koehlerae, B. rocha-limaea, and B. tamiae. The clinical spectrum of infection includes lymphadenopathy, fever of unknown origin, endocarditis, neurological and ophthalmological syndromes, Carrion's disease, and others. This review provides updated information on clinical manifestations and seroepidemiological studies with an emphasis on data available from Brazil.

Bartonella species in rodents and shrews in the greater Jakarta area.

In February 2004, we captured 221 rodents and shrews in the Greater Jakarta area as part of a study to determine the prevalence of rodent-associated vector-borne infections. Microscopic examination of blood smears revealed 6% (13/218) to be positive for Bartonella spp. The corresponding DNA samples, either from blood blots or frozen spleen pieces and from fleas collected on these animals, were tested for evidence of Bartonella infection by PCR, targeting the portions: 378bp and 930bp of the citrate synthase gene (g/tA). The sequences from our sample clusters with a Peruvian entity, B. phoceensis, B. rattimassiliensis and B. elizabethae, the latter species has been associated with endocarditis and neuroretinitis in humans. As previous analyses have shown, there appears to be little geographic or host consistency with phylogenetic placement. The public health significance of these findings remains to be determined.

Enfermedad por arañazo de gato: diferentes presentaciones clínicas en el norte y sur de Chile / Cat-scratch disease: different clinical presentations in the north and south from Chile

Las manifestaciones clínicas y la presentación de la infección por Bartonella henselae posrasguño de gato son muy variadas, por lo que es un diagnóstico que debe tenerse presente para realizarlo. Se presentan los casos de 5 pacientes en los que los estudios por imágenes y la serología fueron de gran utilidad para su confirmación.

Bartonelosis (Carrion's Disease) in the pediatric population of Peru: an overview and update

Bartonellosis, or Carrion's Disease, is an endemic and reemerging disease in Peru and Ecuador. Carrion's Disease constitutes a health problem in Peru because its epidemiology has been changing, and it is affecting new areas between the highland and the jungle. During the latest outbreaks, and previously in endemic areas, the pediatric population has been the most commonly affected. In the pediatric population, the acute phase symptoms are fever, anorexia, malaise, nausea and/or vomiting. The main signs are pallor, hepatomegaly, lymphadenopathies, cardiac murmur, and jaundice. Arthralgias and weight loss have also commonly been described. The morbidity and mortality of the acute phase is variable, and it is due mainly to superimposed infections or associated respiratory, cardiovascular, neurological or gastrointestinal complications. The eruptive phase, also known as Peruvian Wart, is characterized by eruptive nodes (which commonly bleed) and arthralgias. The mortality of the eruptive phase is currently extremely low. The diagnosis is still based on blood culture and direct observation of the bacilli in a blood smear. In the chronic phase, the diagnosis is based on biopsy or serologic assays. There are nationally standardized treatments for the acute phase, which consist of ciprofloxacin, and alternatively chloramphenicol plus penicillin G. However, most of the treatments are based on evidence from reported cases. During the eruptive phase the recommended treatment is rifampin, and alternatively, azithromycin or erythromycin.