Bacillary Angiomatosis Clinical Presentation

Most patients with bacillary angiomatosis are infected with HIV and have CD4⁺ cell counts of less than 200/µL.

The duration of symptoms before diagnosis is usually several months.

Features of skin, subcutaneous, mucosal, and osseous lesions caused by bacillary angiomatosis include the following:

• Raised red or purple lesions in the skin that bleed when traumatized
• Similar lesions in the oral mucosa, tongue, oropharynx, nose, penis, or anus
• Bone pain, frequently in the forearms or legs

Visceral involvement associated with bacillary angiomatosis may be asymptomatic or may cause the following symptoms:

• Fever, chills, malaise, night sweats, anorexia, and weight loss
• Abdominal pain, nausea, and vomiting (peliosis hepatis)
• Jaundice secondary to biliary obstruction caused by external compression of periportal lymph nodes
• Intra-abdominal mass and gastrointestinal bleeding
• Abdominal cramps, tenesmus, and bloody diarrhea (colonic bacillary angiomatosis)
• Psychiatric symptoms, such as exacerbation of depression or new-onset psychosis; personality changes, including anxiety and irritability; headache; trigeminal neuralgia; seizures; or back pain (CNS bacillary angiomatosis)
• Difficulty breathing secondary to laryngeal obstruction

Underlying disease conditions may include the following:

• Commonly, a history of HIV infection, organ transplantation, leukemia, or chemotherapy
• Bacillary angiomatosis developing prior to HIV seroconversion in some patients
• Apparent immunocompetence in some patients

Bacillary angiomatosis was reported in a patient who was HIV-seronegative but had idiopathic thrombocytopenic purpura, had undergone splenectomy, and had been administered long-term systemic prednisone.^[8]

Another recent report described an immunocompetent child with infected facial wound, in the vicinity of which bacillary angiomatosis lesions had developed. Similar lesions also appeared at the donor site of the skin graft, which was grafted on the facial wound.^[9]

Multiple leg ulcers caused by bacillary angiomatosis without a history of direct contact with cats in an adult immunocompetent man has also been reported.^[10]

Bacillary angiomatosis in a pregnant woman was reported from Brazil.^[3]

A case of bacillary angiomatosis in an HIV-negative patient who has chronic hepatitis B but no other immunosuppressive status was reported from Turkey, suggesting immunological differences secondary to chronic hepatitis B could have led to a tendency for the disease development.^[4]

Skin and subcutaneous lesions

Cutaneous lesions due to bacillary angiomatosis may take one of the following forms: (1) solitary or multiple red, purple, flesh-colored, or colorless papules (hemangiomalike lesions) varying in size from 1 mm to several centimeters; (2) nodules, often covered with a fine tightly adherent scale; (3) large, friable, pedunculated, or polypoid exophytic masses; or (4) hyperpigmented, hyperkeratotic, indurated plaques, typically on extremities, often overlying osseous defects.

The number of lesions may vary from 1 to more than 1000, and they are often multiple. The lesions on patients with multiple lesions often demonstrate more than one morphological appearance. Black patients, in particular, may bear the plaque form.

Cutaneous lesions may develop ulceration, discharge, and crusting and are often tender. Smaller lesions tend to be covered with an attenuated epidermis, while larger lesions tend to erode and bleed. Most lesions are rubbery and firm upon palpation and are usually freely mobile. They may be associated with regional lymphadenopathy. Lesions may regress spontaneously, but this is rare.

Subcutaneous nodules may erode through the surface and become friable and superinfected. Deep lesions are usually uncolored and either mobile or fixed to the underlying tissues. They are often tender. The overlying skin may appear normal.

Mucosal lesions

Mucosal lesions are similar to other lesions and may involve oral, conjunctival, nasal, anal, or penile mucosal surfaces.

Ocular complications associated with B henselae infection have been reported in immunocompetent patients and 5 times in HIV-infected patients.^[11] Ocular involvement can range from eyelid involvement to papillitis, hyalitis, and retrobulbar neuritis. Ocular bacillary angiomatosis in an immunocompromised man presenting with an inflammatory eyelid lesion was recently reported.^[12]

Visceral involvement

Visceral involvement may lead to fever, abdominal distension, hepatomegaly, and splenomegaly. This involvement may eventually progress to bacteremia and sepsis syndrome.

Neurological deficits may accompany intracranial mass lesions.

Visceral involvement may occur in the absence of cutaneous lesions. In this case, the diagnosis is often delayed because the manifestations of visceral involvement are nonspecific.

A recent retrospective analysis of 37 speciated bacillary angiomatosis cases demonstrated that fever was present in two thirds of the patients and weight loss in one third of the patients, including patients without extracutaneous involvement.^[13]

Risk factors for bacillary angiomatosis include the following:

• HIV infection
• Chronic lymphocytic leukemia
• Cytotoxic chemotherapy
• Organ transplantations

Additional risk factors for bacillary angiomatosis associated with B henselae infection include the following:

• Cat ownership
• Cat bites
• Cat scratches

Additional risk factors for bacillary angiomatosis associated with B quintana infection include the following:

• Homelessness
• Low socioeconomic status
• Exposure to body and hair lice