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Chapter 3Infectious Diseases Related To Travel
Bartonella-Associated Infections
Alicia Anderson, Jennifer McQuiston
INFECTIOUS AGENT
At least a dozen bacterial species in the genus Bartonella cause several different diseases, but few are significant causes of human illness. Cat-scratch disease (CSD) is caused by Bartonella henselae. Bartonellosis (Carrión disease) results from infection with B. bacilliformis. This disease has 2 distinct phases: an acute febrile illness (Oroya fever) and an eruptive phase, manifesting as cutaneous lesions (verruga peruana). Trench fever is caused by B. quintana. A variety of Bartonella spp. have been associated with culture-negative endocarditis.
MODE OF TRANSMISSION
CSD is contracted through scratches and bites from domestic or feral cats, particularly kittens. The disease occurs most frequently in children aged <10 years. Cats acquire the organism from infected fleas. Infected flea dirt is harbored in their claws when they scratch themselves and may then be transmitted to a person or another cat.
Bartonellosis is transmitted by sand flies (genus Lutzomyia) that are infected with the organism. Much is still unknown regarding the existence of other competent arthropod vectors and the identification of a natural, nonhuman, vertebrate reservoir. Trench fever is transmitted by the human body louse. Because of its association with body louse infestations, trench fever is most commonly associated with homeless populations or areas of high population density and poor sanitation.
EPIDEMIOLOGY
CSD occurs worldwide and may be present wherever cats are found. Stray cats may be more likely than pets to carry Bartonella. In the United States, most cases occur in the fall and winter. Bartonellosis has limited geographic distribution; cases occur in the Andes Mountains in western South America, including Peru, Colombia, and Ecuador. Most cases are reported in Peru. A few cases of Oroya fever and verruga peruana (Peruvian wart) have been reported in travelers who returned from the Andean highlands in South America, but the risk is low. In 2007, a newly recognized species of Bartonella (B. melophagi) was identified in an ill traveler returning from Peru. Trench fever has a worldwide distribution; cases have been reported from Europe, North America, Africa, and China.
CLINICAL PRESENTATION
The symptoms of CSD include fever; enlarged, tender lymph nodes that develop 1–2 weeks after exposure; and a papule or pustule at the inoculation site. Unusual manifestations such as granulomatous conjunctivitis, neuroretinitis, atypical pneumonia, or endocarditis may occur in a small percentage of patients. The manifestations of Oroya fever include fever, myalgia, headache, and anemia. The case-fatality ratio may exceed 40% in untreated people. Verruga peruana is characterized by red-to-purple nodular skin lesions. The symptoms of trench fever include fever, headache, a transient rash, and bone pain, mainly in the shins, neck, and back.
Bacillary angiomatosis (caused by B. henselae or B. quintana) and peliosis hepatis (caused by B. henselae) occur primarily in people infected with HIV. They may present as skin, subcutaneous, or bone lesions. Many Bartonella spp. can cause signs and symptoms of subacute endocarditis, which is often culture-negative.
DIAGNOSIS
Diagnosis of CSD can be made by detection of B. henselae DNA by PCR, or in culture of pus or lymph node aspirates by using special techniques. CSD is usually confirmed by serology. Oroya fever is typically diagnosed via blood culture or direct observation of the bacilli in peripheral blood smears. Diagnosis of trench fever can be made by isolation of B. quintana from blood cultured on blood or chocolate agar under 5% CO2. Microcolonies can be seen after 1–3 weeks of incubation at 37°C. Trench fever can also be confirmed by serology. PCR technology is improving the diagnosis of disseminated Bartonella infections. Endocarditis remains difficult to diagnose. Sometimes serology is helpful, or PCR may be done on valve tissue.
TREATMENT
Most cases of CSD eventually resolve without treatment, but a small percentage of people will develop disseminated disease with severe complications. The use of antibiotics to shorten the course of disease is controversial, although azithromycin administered for 5 days has been shown to decrease lymph node volume (500 mg on day 1, followed by 250 mg for 4 days for patients weighing >45.5 kg; or 10 mg/kg on day 1, followed by 5 mg/kg for 4 days for those weighing <45.5 kg).
A wide range of antibiotics is effective against Bartonella infections, including penicillins, tetracyclines, cephalosporins, aminoglycosides, and fluoroquinolones. Often, with serious infections, more than one antibiotic is used. Physicians should consult with an expert in infectious diseases.
PREVENTIVE MEASURES FOR TRAVELERS
For CSD, travelers should avoid rough play with cats, particularly strays, to prevent scratches or bites and should wash hands promptly after handling cats. Preventive measures for Oroya fever include protecting against sand flies via clothing, repellents, and reduced outdoor activities when sand flies are most active (dusk and dawn). Preventive measures for trench fever include avoiding exposures to human body lice.
BIBLIOGRAPHY
- Bass JW, Freitas BC, Freitas AD, Sisler CL, Chan DS, Vincent JM, et al. Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease. Pediatr Infect Dis J. 1998 Jun;17(6):447–52.
- Chamberlin J, Laughlin LW, Romero S, Solorzano N, Gordon S, Andre RG, et al. Epidemiology of endemic Bartonella bacilliformis: a prospective cohort study in a Peruvian mountain valley community. J Infect Dis. 2002 Oct 1;186(7):983–90.
- Fournier PE, Thuny F, Richet H, Lepidi H, Casalta JP, Arzouni JP, et al. Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Clin Infect Dis. 2010 Jul 15;51(2):131–40.
- Guptill L, Wu CC, HogenEsch H, Slater LN, Glickman N, Dunham A, et al. Prevalence, risk factors, and genetic diversity of Bartonella henselae infections in pet cats in four regions of the United States. J Clin Microbiol. 2004 Feb;42(2):652–9.
- Maguina C, Gotuzzo E. Bartonellosis. New and old. Infect Dis Clin North Am. 2000 Mar;14(1):1–22, vii.
- Margileth AM. Cat scratch disease. Adv Pediatr Infect Dis. 1993;8:1–21.
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