para>Advise lab if Bartonella infection is suspected so that cultures are prepared using appropriate media and laboratory conditions; prolonged incubation is required (up to 6 weeks).
Polymerase chain reaction (PCR; highly sensitive) of valve tissue can aid in diagnosis of endocarditis; otherwise, less helpful; not widely available (3)
Antibiotics may result in false-negative culture.
Lab and other workup not required for typical CSD in nontoxic immunocompetent patients
Diagnostic Procedures/Other
Biopsy of lymph nodes for histology and culture if needed; consider biopsy of involved organs.
Test Interpretation
- CSD: granulomas, stellate necrosis, mixed inflammatory infiltrates; bacilli in tissue may be visible using silver impregnation stains (Warthin-Starry).
- Verruga peruana: neovascular proliferation; bacteria is not usually identified.
- Endocarditis: Warthin-Starry-stained bacilli may be seen in vegetations.
- Bacillary angiomatosis
- Lobular proliferations of small blood vessels with cuboidal endothelial cells interspersed with inflammatory cells, mostly neutrophils.
- Warthin-Starry stain or electron microscopy may show clusters of bacilli.
- Bacillary peliosis: blood-filled cystic structures; Warthin-Starry stain may show surrounding clumps of bacilli.
TREATMENT
Many cases of CSD are self-limited. Base antibiotic treatment on clinical presentation and disease severity.
MEDICATION
- Antipyretics and analgesics for symptom management
- Antibiotic choice depends on clinical situation often based on case studies and expert opinion (2)[A].
- Typical CSD: no clear benefit, azithromycin may speed resolution of extensive lymphadenopathy: adults and children >45.5 kg: 500 mg on day 1,250 mg daily on days 2 to 5; children <45.5 kg: 10 mg/kg on day 1, 5 mg/kg daily on days 2 to 5 (2)[A]
- Bacteremia: gentamicin 3 mg/kg IV daily for 2 weeks and doxycycline 200 mg PO daily for 4 weeks (2)[B]
- Oroya fever: chloramphenicol 500 mg (pediatric dose 50 mg/kg/day) PO/IV QID+/- β-lactam (IV: PCN G 3 million U q4h [40,000 units/kg q4h for pediatrics]/PO: PCN V 500 mg QID or 20 mg/kg QID for pediatrics) for 14 days or ciprofloxacin 500 mg BID for 10 days (2)[B]
- Verruga peruana: rifampin 600 mg PO daily (10 mg/kg/day in children [not to exceed 600 mg/day]) for 2 to 3 weeks (2)[B]
- Neuroretinitis: doxycycline 100 mg PO BID (in children <8 years old, consider erythromycin 20 mg/kg/day to maximum daily dose of 2 g/day) + rifampin 300 mg PO BID for 4 to 6 weeks (2)[B]. Usually self-limited, so some authors suggest no antibiotics are needed.
- Trench fever or chronic B. quintana bacteremia without endocarditis: gentamicin 3 mg/kg IV daily for 2 weeks and doxycycline 200 mg PO daily for 4 weeks (2)[A]
- Bacillary angiomatosis/peliosis: erythromycin 500 mg (pediatric dose 40 mg/kg/day to maximum daily dose of 2 g/day) PO QID or doxycycline 100 mg PO BID for 3 months (4 months for peliosis) (2,3)[B]
- Endocarditis: gentamicin 1 mg/kg IV TID for 2 weeks + doxycycline 100 mg IV/PO BID for 6 weeks (2,3)[B]
ALERT
All HIV-infected patients should receive antibiotic treatment (3)[A].
ISSUES FOR REFERRAL
Cardiothoracic surgery if endocarditis
SURGERY/OTHER PROCEDURES
- Drain lymph nodes with needle aspiration (usually not necessary).
- Valve replacement if indicated in endocarditis
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Consider admission for patients who are immunocompromised, hemodynamically unstable, or may not have access to appropriate antibiotics.
- High degree of clinical suspicion and awareness of infection risk
Discharge Criteria
When hemodynamically stable on oral antibiotics or receiving IV antibiotics through a peripherally inserted central catheter line and fevers have resolved.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Immunocompromised patients have increased risk for relapse. Extended periods of antibiotics are recommended.
DIET
No diet modifications needed
PATIENT EDUCATION
- Educate patients about proper vector control.
- Immunocompromised patients:
- Consider risk/benefit of cat ownership (3)[A].
- Only adopt cats >1 year old that are healthy and free of fleas (3)[B].
- No need to declaw cat, but avoid rough play (3)[A].
- Immediately wash cat-induced wounds (3)[B].
- Regular use of cat flea control (3)[B].
- No benefit in testing cats for Bartonella (3)[B]
PROGNOSIS
- CSD: spontaneous resolution usually in 2 to 4 months without specific therapy
- Other syndromes: with proper treatment, full resolution; if relapse, consider long-term suppressive antibiotics.
- Oroya fever: if untreated, 40-85% mortality
COMPLICATIONS
Disseminated disease can present with specific organ-related findings such as focal seizures or renal microabscesses.
REFERENCES
11 Kaiser PO, Riess T, O'Rourke F, et al. Bartonella spp.: throwing light on uncommon human infections. Int J Med Microbiol. 2011;301(1):7-15.22 Angelakis E, Raoult D. Pathogenicity and treatment of Bartonella infections. Int J Antimicrob Agents. 2014;44(1):16-25.33 Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed August 14, 2015; J1-J5.44 Vermeulen MJ, Verbakel H, Notermans DW, et al. Evaluation of sensitivity, specificity and cross-reactivity in Bartonella henselae serology. J Med Microbiol. 2010;59(Pt 6):743-745.
ADDITIONAL READING
Prutsky G, Domecq JP, Mori L, et al. Treatment outcomes of human bartonellosis: a systematic review and meta-analysis. Int J Infect Dis. 2013;17(10):e811-e819.
CODES
ICD10
- A44.9 Bartonellosis, unspecified
- A28.1 Cat-scratch disease
- A79.0 Trench fever
- A44.1 Cutaneous and mucocutaneous bartonellosis
- A44.8 Other forms of bartonellosis
- A44.0 Systemic bartonellosis
ICD9
- 088.0 Bartonellosis
- 078.3 Cat-scratch disease
- 083.1 Trench fever
SNOMED
- Bartonellosis (disorder)
- Cat scratch disease (disorder)
- Trench fever
- Oroya fever
CLINICAL PEARLS
- Diagnosing Bartonella infections requires a high degree of clinical suspicion.
- CSD is self-limited in most immunocompetent patients.
- Immunocompromised patients are at increased risk for occult infections.
- CSD can be prevented by avoiding stray cats and ensuring proper flea and tick control in domestic pets.