Bartonella Species

Clinical Background

Bartonella species are the cause of several different diseases, including cat scratch disease.

Epidemiology

B. henselae
- Prevalence - 22,000 infections per year; most common in warm, humid climates during autumn and winter
- Transmission - usually cats
  - Children younger than 1 year have the greatest rate of transmission
  - Transmitted between cats via cat flea, but not to humans
  - Most afflicted patients do not recall being scratched by a cat
B. quintana
- Prevalence - generally low; however, increasing incidence in homeless populations in U.S. and Europe
- Transmission - body louse (Pediculus humanus corporis)

Organism

Bartonella is a gram-negative bacillus that can adhere to and invade mammalian cells
Bartonella species are associated with 4 primary clinical syndromes:
- Bacillary angiomatosis (BA) (B. quintana, B. henselae)
- Bacillary peliosis hepatitis (B. henselae)
- Relapsing fever with bacteremia (trench fever) (B. quintana)
- Cat scratch disease (B. henselae, B. clarridgeiae)

Risk Factors

B. henselae
- Rough play with cats, especially kittens
- Unwashed cat bites and scratches
- Allowing cats to lick open wounds
- Fleas
B. quintana
- Immunocompromised persons (HIV in particular)
- Homelessness
- Alcoholism

Clinical Presentation

B. henselae
- Immunocompetent host
  - Common presentations
  - A localized papule (which progresses to a pustule) develops 3-5 days after cat scratch
  - Tender regional lymphadenopathy develops 1-2 weeks later
    - Cervical and axillary are the most common
  - Secondary bacterial superinfection of involved nodes is not uncommon
  - Other manifestations (less common) - encephalitis, hepatitis, osteomyelitis and disseminated infection
  - Uncommon presentation
    - Conjunctival inoculation may cause Parinaud oculoglandular syndrome with conjunctivitis and periauricular lymphadenopathy
- Immunocompromised host
  - Bacillary angiomatosis
    - Nontender firm red-purple colored skin lesions
      - Dissemination to organs if not treated
  - Bacillary peliosis
    - Vasoproliferation within the liver and spleen
      - Blood-filled cysts with possible organisms in the cysts (identified with Warthin silver stain)
B. quintana
- Trench fever
  - Relapsing fever with bacteremia
  - Sudden onset headache, meningitis and relapsing fever
  - Relapses common when short course antibiotics are used
  - May cause endocarditis
- Bacillary angiomatosis
  - Many organs may be affected - liver, spleen, bone marrow, lymph nodes
  - Hallmark symptoms are vascular nodules and papules or tumors, with proliferation of new blood vessels (angiogenesis)
  - Lesions, termed epithelioid angiomatosis, resemble Kaposi sarcoma

Treatment

B. henselae
- Central nervous system involvement or other serious disease must be treated
B. quintana
- Prolonged course of antibiotic treatment required

See Also

Brucella

Francisella tularensis

Tests

Tests generally appear in the order most useful for common clinical situations

Test name: Bartonella henselae (Cat Scratch) Antibodies, IgG & IgM by IFA

ARUP #: 0050108

Methodology: Indirect Fluorescent Antibody

Use:

Order when current or past exposure to B. henselae suspected

Limitations:

Follow-up:

If test results equivocal, repeat testing in 10-14 days may be helpful

Test name: Bartonella quintana Antibodies, IgG & IgM by IFA

ARUP #: 0050106

Methodology: Indirect Fluorescent Antibody

Use:

Identify Bartonella quintana as disease pathogen (70-90% of patients)

Limitations:

False-negatives may occur in HIV/AIDS patients

Bartonella quintana antibodies may be cross-reactive with:

Bartonella vinsonii and Bartonella henselae
Some of the Rickettsial organisms
- Approximately 50% of typhus group (Rickettsia prowazekii and Rickettsia mooseri)
- Approximately 66% of scrub typhus (Orientia tsutsugamushi)
Rarely cross-reactive with sera from spotted fever group organisms (Rickettsia rickettsii and Rickettsia akari)

Bartonella quintana antibodies may be seen in patients with bacillary angiomatosis and/or parenchymal bacillary peliosis

Follow-up:

If test results are equivocal, repeat testing in 10-14 days

Low positive IgG result suggests past exposure or infection; high positive result may indicate current or recent infection but not conclusively

While IgM antibodies suggest recent infection, low IgM levels may occasionally persist >12 months post-infection

Best evidence of infection is significant change on 2 appropriately timed specimens, where both tests are performed in same laboratory at same time

Test name: Bartonella DNA Detection by PCR, Whole Blood

ARUP #: 0060762

Methodology: Polymerase Chain Reaction

Use:

Rapid test for whole blood

Use with antibody tests

Clarify negative antibody test results in symptomatic patients

In epidemiological situations, determine Bartonella species (sequencing of PCR product)

Limitations:

A negative result does not rule out the presence of Bartonella spp DNA in quantities below the sensitivity of assay or the possibility of PCR inhibitors in samples

Unidentified sequence variations within the htrA gene of Bartonella may lead to a false-negative result

Follow-up:

Test name: Bartonella DNA Detection by PCR

ARUP #: 0093057

Methodology: Polymerase Chain Reaction

Use:

Rapid test for serum, plasma, CSF or tissue

Use with antibody tests

Clarify negative antibody test results in symptomatic patients

In epidemiological situations, determine Bartonella species (sequencing of PCR product)

Limitations:

A negative result does not rule out the presence of Bartonella spp DNA in quantities below the sensitivity of assay or the possibility of PCR inhibitors in samples

Unidentified sequence variations within the htrA gene of Bartonella may lead to a false-negative result

Follow-up:

Test name: Immunohistochemistry Stain Offering

ARUP #: Arup005

Methodology: Immunohistochemistry

Use:

Detect Bartonella quintana in angiomas

For fixed tissue samples, consultative services as well as immunohistochemical staining for B. henselae are available

Test name: Blood Culture

ARUP #: 0060102

Methodology: Bactec® 9240, continuous monitoring system. Standard reference procedures for identification of aerobic and anaerobic microorganisms

Use:

Time-sensitive test
Use in patients with endocarditis to determine presence of Bartonella species

Test name: Tissue Culture (Includes Gram Stain 0060101)

ARUP #: 0060127

Methodology: Standard reference procedures for bacterial stain, aerobic culture, and identification. Anaerobe culture performed on properly collected specimens.

Use:

Time-sensitive test

Specify Bartonella as species of interest

Additional Tests Available

Test name: Bartonella henselae Antibody, IgG by IFA

ARUP #: 0050091

Methodology: Indirect Fluorescent Antibody

Comments:

Test name: Bartonella henselae Antibody, IgM by IFA

ARUP #: 0050092

Methodology: Indirect Fluorescent Antibody

Comments:

Test name: Bartonella quintana Antibody, IgG by IFA

ARUP #: 0050094

Methodology: Indirect Fluorescent Antibody

Comments:

Test name: Bartonella quintana Antibody, IgM by IFA

ARUP #: 0050093

Methodology: Indirect Fluorescent Antibody

Comments:

References

General References

Brouqui P, Raoult D. Arthropod-borne diseases in homeless. Ann N Y Acad Sci. 2006;1078:223-235.

Chomel BB, Kasten RW, Sykes JE, Boulouis HJ, Breitschwerdt EB. Clinical impact of persistent Bartonella bacteremia in humans and animals. Ann N Y Acad Sci. 2003;990:267-278.

Chomel BB, Boulouis HJ, Maruyama S, Breitschwerdt EB. Bartonella spp. in pets and effect on human health. Emerg Infect Dis. 2006;12(3):389-394.

Comer JA, Paddock CD, Childs JE. Urban zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vector Borne Zoonotic Dis. 2001;1(2):91-118.

English R. Cat-scratch disease. Pediatr Rev. 2006;27(4):123-128.

Foucault C, Brouqui P, Raoult D. Bartonella quintana characteristics and clinical management. Emerg Infect Dis. 2006;12(2):217-223.

Karem KL, Paddock CD, Regnery RL. Bartonella henselae, B. quintana, and B. bacilliformis: historical pathogens of emerging significance. Microbes Infect. 2000;2(10):1193-1205.

Lamps LW, Scott MA. Cat-scratch disease: historic, clinical, and pathologic perspectives. Am J Clin Pathol. 2004;121 Suppl:S71-S80.

Raoult D, Foucault C, Brouqui P. Infections in the homeless. Lancet Infect Dis. 2001;1(2):77-84.

Rolain JM, Brouqui P, Koehler JE, Maguina C, Dolan MJ, Raoult D. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother. 2004;48(6):1921-1933.

Windsor JJ. Cat-scratch disease: epidemiology, aetiology and treatment. Br J Biomed Sci. 2001;58(2):101-110.

Zeaiter Z, Fournier PE, Greub G, Raoult D. Diagnosis of Bartonella endocarditis by a real-time nested PCR assay using serum. J Clin Microbiol. 2003;41(3):919-925.

References from the ARUP Institute for Clinical and Experimental Pathology Research®

Litwin CM, Johnson JM. Identification, cloning, and expression of the CAMP-like factor autotransporter gene (cfa) of Bartonella henselae. Infect Immun. 2005;73(7):4205-4213.

Litwin CM, Rawlins ML, Swenson EM. Characterization of an immunogenic outer membrane autotransporter protein, Arp, of Bartonella henselae. Infect Immun. 2007;75(11):5255-5263.

Medical Reviewers

Carney, Heather, M.D. Assistant Medical Director, Transfusion Services at ARUP Laboratories; Pathology, University of Utah

Hillyard, David R., M.D. Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Associate Professor, Pathology, University of Utah

Litwin, Christine, M.D. Medical Director, Immunology at ARUP Laboratories; Professor, Clinical Pathology, University of Utah

Petti, Cathy A., M.D. Medical Director, Infectious Diseases at ARUP Laboratories; Assistant Professor, Pathology and Medicine, University of Utah

Comprehensive Review: July 2008
Last Update: September 2008