Gram-negative
Intracellular
Grow on solid media (shell vial tissue cultures, blood enriched)
Epidemiology/Pathology
Bartonella bacilliformis
Human reservoir
Found between altitudes 800 and 3,000 m on the western slopes of the Andes Mountains in the countries of Columbia, Peru, and Ecuador
Sandfly transmission (Lutzomyia verrucarum)
The bacteria destroy red cells and invade cells of the reticuloendothelial system (RES).
Nucleated RBCs and reticulocytes, intravascular hemolysis
Clinical
Bacteremic phase, Oroya Fever
Primary bacteremia
≥3-week incubation period
Fever
Malaise
Anemia
Head, abdominal, and joint and long bone pain
The liver, spleen, and lymph nodes are enlarged and often tender.
≥30% death rate by 3 weeks
Superinfection with salmonella is common, up to 50%
Salmonellosis is the most frequent complication, occurring in 40% to 50% of cases of Oroya fever. Toxoplasmosis has been reported as well.
Parotitis, thromboses, pleurisy, and meningoencephalitis may complicate the infection in some patients.
Eruptive phase, verruga peruana
Crops of skin lesions occur several weeks to-months after resolution of the initial infection.
Miliary or nodular lesions
Face and legs > trunk
May also occur with visceral involvement, especially dysphagia and vaginal bleeding
Table 42-1 Diagnostic Tests for Bartonella
Warthin-Starry Silver Stain
Culture
Serology
Giemsa Stain of Blood
PCR
Oroya Fever
+
+
+ (travelers)
++
+
Typical CSD
+
+ (20%)
++
+ tissue
CNS
+
Endocarditis
+
+
++
BA
+
+
+
PH
+
+
+
Neuroretinitis
+
+
Trench Fever
+
+
+
Recurring crops over several months is not uncommon.
As seen in yaws, the constitutional symptoms disappear with the appearance of the skin lesions.
Diagnosis (see Table 42-1)
The organism can be seen in the red cells during Oroya fever and in smears from verruga lesions.
Can be cultured from the blood on special media
Serology is usually not helpful
Treatment (see Table 42-2)
Chloramphenicol (2 to 4 gm daily in divided doses) for 1 to 2 weeks is the traditional antibiotic of choice in South America.
Other effective antibiotics include tetracycline, streptomycin, rifampin, cipro-floxacin, ampicillin, and cotrimoxazole.
Epidemiology
Pediculus humanus, the human body louse, is the vector.
B. quintana has historically caused worldwide outbreaks of trench fever.
1 million people infected during WWI
B. quintana presentations commonly seen today:
Asymptomatic infections
A relapsing febrile illness with headache and legpain
A cause of “culture-negative” endocarditis
May cause bacillary angiomatosis (BA), chronic lymphadenopathy, bacteremia, and endocarditis in HIV-infected patients
Outbreaks in homeless patients, most notably in Seattle and France. Associated with poverty and alcoholism
Clinical Features
Classic trench fever
Transmission occurs primarily by the rubbing of louse feces into broken skin. Less often by actual biting by the lice
Incubation period was usually 7 days but ranged from 3 to 38 days
Onset of fever and chills was usually sudden, resembling influenza
Table 42-2 Treatment Options for Bartonella
Drugs of Choice
Alternates
Comments
CSD
None, as the course is self-limited in most patients.
Azithromycin is dosed 500 mg PO on day 1, then 250 mg PO on days 2-5 as a single daily dose.
Only treat for bulky or extensive lymphadenopathy.
No evidence it will prevent complications.
Oroya Fever
Chloramphenicol at 500 mg PO or IV q.i.d. for 14 days plus a beta-lactam.
Ciprofloxacin 500 mg PO b.i.d. for 10 days. Perhaps trimethoprim- sulfamethoxazole.
Verruca
Rifampin 10 mg/kg/day PO for 14 days
Streptomycin at 15-20 mg/kg/day IM for 10 days.
Suspected Bartonella endocarditis
Gentamicin at 3 mg/kg/day.IV for 14 days and ceftriaxone at 2 g IV or IM q.d. for 6 weeks with or without doxycycline at 100 mg PO or IV b.i.d. for 6 weeks
Documented Bartonella endocarditis
Doxycycline at 100 mg PO b.i.d. for 6 weeks and Gentamicin at 3 mg/kg/day IV for 14 days.
Retinitis
Doxycycline at 100 mg PO b.i.d. for 4-6 weeks and rifampin at 300 mg PO b.i.d. for 4-6 weeks
Steroids are of unproven benefit but may be recommended by ophthalmology.
Trench Fever and B. quintana bacteremia.
Doxycycline at 200 mg PO q.d. for 4 weeks plus gentamicin 3 mg/kg IV q.d. for 2 weeks
BA
Erythromycin at 500 mg PO q.i.d. for 3 months
Or doxycycline at 100 mg PO b.i.d. for 3-4 months.
PH
Erythromycin at 500 mg PO q.i.d. for 4 months.
Or doxycycline at 100 mg PO b.i.d. for 3-4 months.
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