Bartonellosis is a group of diseases caused by bacteria from the genus Bartonella, occurring with a predominant lesion of endothelial cells and erythrocytes. Clinical manifestations can be different: from mild and local (rash, lymphadenopathy, conjunctivitis) to common systemic disorders (fever, anemia, septic bacteremia, endocarditis, meningitis, myelitis). Diagnosis of bartonellosis is based on the detection of the pathogen itself, as well as its antigens and antibodies in the patient’s blood. Therapy is carried out with antibacterial drugs (tetracyclines, macrolides, fluoroquinolones), according to indications, supplemented with symptomatic treatment (antipyretics, detoxification therapy).
ICD 10
A44 Bartonellosis
General information
The group of bartonellosis includes felinosis, trench fever, Carrion disease, bacillary angiomatosis, bartonellosis syndrome with bacteremia and endocarditis, peliotic hepatitis/splenitis, chronic lymphadenopathy. Chronologically, Carrion’s disease was studied first among all the variety of clinical variants of infection, so bartonellosis is usually identified with it. The northwestern territories of South America are endemic areas for the disease. This is due to the habitat of the vector of bacteria – mosquitoes phlebotomus. The peak incidence of bartonellosis occurs during the rainy season, when mosquitoes are especially active. Other forms of infection do not have a clear geographical location, which is explained by the ubiquity of Bartonella on the planet.
Causes
Bartonella are gram-negative aerobic sticks. They are capable of causing bacteremia, persist in the host body inside red blood cells. They die quickly under the influence of conventional disinfectants. The causative agent of Carrion disease is B. bacilliformis. In addition, pathogenic to humans are B. henselae (causes felinosis, bacillary angiomatosis), B. quitana (causes the development of trench fever, bacillary angiomatosis, bacteremia and endocarditis), B. vinsonii and B. elizabethae (cause bacteremia, endocarditis), B.grahamii (causes neuroretinitis), B. washoesis (promotes the development of myocarditis).
Bacteria enter the human body through mosquito bites, ticks, lice or micro-damage to the skin. The reservoir of infection is a person with acute forms, or an asymptomatic bacterial carrier. The frequency of asymptomatic bacteremia in carriers of infection reaches 50%. The susceptibility to bartonellosis in residents of endemic areas is high. Unsanitary conditions, crowding of people contribute to an increase in the frequency of infection.
Pathogenesis
At the site of penetration of the pathogen, a primary affect is formed – a papule, vesicle or pustule. Further, with the flow of lymph, the pathogen penetrates into the lymph nodes – lymphadenopathy develops. When the lymphatic barrier is overcome, the pathogen enters the bloodstream – bacteremia occurs. The most sensitive to bartonella are erythrocytes and vascular endothelial cells, bone marrow, heart valves. Active reproduction of the pathogen in erythrocytes and their destruction causes the development of hemolytic anemia.
In acute processes, necrotic changes prevail in endothelial cells, the vascular wall is infiltrated by leukocytes and macrophages with the formation of granulomas, the phenomena of proliferation are expressed insignificantly. Small hemorrhages appear in the mucous membranes and skin. The chronic course of bartonellosis is characterized by the formation of new small vessels with the formation of angioendotheliomas. With the consistency of the immune system, antibodies are formed with the subsequent elimination of the pathogen. In the case of immunodeficiency states, the process is chronicled with a long-term persistence of bartonella in the blood. The lack of treatment in such a situation can lead to death. In recovered patients, a stable immunity is formed.
Classification
Bartonellosis is a group of diverse diseases. There is no unified classification of nosologies, since bartonella are not fully studied bacteria, new information about the lesions caused by them appears; in addition, some forms may flow into others. To date, the following diseases caused by bartonella are known:
- Carrion disease. An anthroponotic infectious disease with a transmissible transmission mechanism, occurring as an acute or chronic form. Characterized by fever, lymphadenopathy, headaches, myalgia, arthralgia, petechial rash on the skin and mucous membranes.
- Fellinosis (cat scratch disease, benign lymphoreticulosis, granuloma Mollare, Caesari’s lymphoreticulitis). A typical clinical picture is the presence of primary affect, fever, enlarged regional lymph nodes. An atypical course is also possible: Parino syndrome (fever, lymphadenopathy, follicular conjunctivitis), central nervous system damage (meningitis, encephalitis, polyneuritis) and various organs (pneumonia, myocarditis, spleen abscesses).
- Bacillary (epithelioid) angiomatosis. The lesion of the skin and internal organs is characteristic. At the same time, angiomas are formed subcutaneously on the skin, which are easily injured and bleed. In case of involvement of internal organs, the temperature rises, vomiting, sweating, weight loss appear, pneumonia, spleen abscesses, bone marrow lesions develop.
- Trench fever (tibial or five-day fever). Patients complain of severe headaches, pain in the back, neck, bones, especially tibial (tibial fever). In some patients, a roseolous rash appears. Temperature rises are characteristic every five days (five-day fever). The prognosis is favorable, with chronization, the development of endocarditis is possible.
- Hepatic and splenic purpura (bacillary purple hepatitis, pelagic hepatitis). It is a form of bacillary angiomatosis with predominant involvement of the liver or spleen. The formation of multiple cavities filled with blood in the organs is characteristic. Fever, nausea, vomiting, and congestion in the liver are clinically determined due to compression by newly formed vascular cavities.
- Bacteremia, endocarditis. There are no typical symptoms characteristic of bartonellosis. Clinically manifested by severe intoxication, damage to various organs and tissues (spleen, liver, central nervous system), the development of DIC syndrome. With endocarditis, noises of various types appear, decompensation of the cardiovascular system develops.
Symptoms of bartonellosis
Carrion disease is a staged process. It can occur in the form of an acute (Oroya fever) or a chronic phase (Peruvian wart). Simultaneous development of the clinic of both stages is possible. In the classic version, the chronic stage replaces the acute one after 1-2 months.
The incubation period of bartonellosis is from 10 to 120 days (on average about 2 months). When the clinical picture unfolds, fever of the wrong type appears, a rise in temperature to 39-40 ° C is accompanied by chills, and a decrease in sweating, resembling malaria. Patients complain of headaches, malaise, abdominal pain, joints, muscles. Marked pallor due to anemia is characteristic. Various symptoms of neurological status disorders may appear up to the development of coma. Small hemorrhages occur on the skin and mucous membranes. The liver, spleen, and lymph nodes are enlarged. With a favorable outcome of the disease, a person recovers, but without treatment, the mortality rate ranges from 40 to 90%.
With the preservation of the pathogen in the body, bartonellosis passes into a latent stage with subsequent reactivation and the development of a chronic phase ‒ the Peruvian wart. The temperature rises again. Papular rash appears on the body, which eventually transforms into nodules from 3 mm to several centimeters in diameter. Most often, rashes are localized on the face, neck, limbs. There is a lesion of the mucous membranes of the mouth, vagina, gastrointestinal tract, etc. Nodes can bleed and ulcerate with the addition of a secondary infection. With a favorable course after 1-2 months. recovery comes, nodes are resolved without scarring.
Complications
The most common complication is the attachment of a secondary salmonella infection. In the case of the development of a septic form of the disease, the mortality rate increases sharply. In addition, it is possible to infect ulceration rashes with a Peruvian wart, in which case the wounds heal with a scar. When the mucous membranes are affected, bleeding occurs. Bacteremia and multiple organ lesions contribute to the development of sepsis, which is usually accompanied by DIC syndrome. A high degree of regurgitation on the heart valves leads to the failure of the compensatory capabilities of the heart, which requires surgical replacement of the valve. CNS lesions lead to neurological deficiency, bacillary angiomatosis contributes to the suppression of liver functions.
Diagnostics
If bartonellosis is suspected, it is necessary to consult a therapist, an infectious disease specialist, a dermatologist, in case of damage to the nervous system – a neurologist, the development of purulent complications – a surgeon. During physical examination, pallor is noted, primary affect with regional lymphadenopathy on the skin, enlarged liver, spleen on palpation. The following laboratory and instrumental methods are used in diagnostics:
- Blood tests. In general and biochemical blood tests, hemolytic macrocytic normo- or hypochromic anemia, markers of inflammation (CRP, procalcitonin, increased globulin levels), acceleration of ESR are observed. There may be no leukocytosis, with thrombosis there is a decrease in fibrinogen indicators, an increase in the level of D-dimers.
- Direct detection of the pathogen. Microscopy of blood smears stained according to Romanovsky–Giemsa reveals pathogenic microorganisms outside and inside the blood cells. Also, biopsy material from lymph nodes or rash elements can be used as a preparation. According to the blood culture, it is possible to pre–judge the presence and degree of bacteremia after 3 days, finally after 7-10 days. The DNA of the pathogen is identified by PCR.
- Serological diagnostic methods. Antibodies (IgM and IgG) are determined in the patient’s blood serum by the method of hemagglutination reaction, compliment binding, indirect immunofluorescence, enzyme immunoassay. To detect bartonella antigens, immunoblotting and Western blotting are performed.
- Ultrasound of the abdominal cavity. Abdominal ultrasound is not a specific method of detecting bartonellosis. During the procedure, an increase in the liver, spleen, intra-abdominal lymph nodes is determined. It is possible to detect fluid-filled cavities in parenchymal organs, foci of proliferation. Such a picture can resemble many other diseases.
Differential diagnosis of bartonellosis is carried out with the cutaneous form of tuberculosis, angiosarcoma, skin tumor, in particular myeloma. The more common nosology – felinosis – should be distinguished from atypical mycobacteriosis, syphilis, tularemia, lymphoma. Differential diagnosis of bacillary angiomatosis should be carried out with Kaposi’s sarcoma, angioma, squamous cell and basal cell carcinoma. Endocarditis and bacteremia must be distinguished from similar diseases caused by other pathogens.
Treatment of bartonellosis
Treatment is carried out in an infectious disease hospital. It is necessary to observe bed rest. Etiotropic therapy with antibacterial drugs is carried out. Since the subsequent secondary addition of salmonellosis is possible, it is rational to use ciprofloxacin or chloramphenecol in combination with a beta-lactam antibiotic. The reserve drugs are macrolides, tetracyclines, rifampicin. If necessary, symptomatic treatment is prescribed (detoxification therapy, antipyretic drugs, hepatoprotectors, transfusion of erythrocyte mass). Bandages with antibacterial ointments are applied to infected skin elements after washing with antiseptics.
Prognosis and prevention
In the acute phase, in the absence of concomitant pathology and timely treatment, the prognosis is favorable. However, with immunosuppression with massive bacteremia, it is possible to develop bacillary angiomatosis, lesions of the nervous system, decompensation of cardiac activity due to valve damage. In the stage of the Peruvian wart, lethal cases are practically not described, mortality is associated with the addition of infection. Specific prevention of bartonellosis has not been developed. Individual protection measures include the use of repellents, mosquito nets.
