eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Bacillary Angiomatosis: Differential Diagnoses & Workup

Author: KoKo Aung, MD, MPH, FACP, Assistant Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
Coauthor(s): Thwe T Htay, MD, Assistant Professor, Department of Medicine, University of Texas Health Science Center at San Antonio; Romeo Papica II, MD, Research Associate, Department of Internal Medicine, Texas Tech University Health Sciences Center; Harvey Kantor, MD, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Texas Tech University Health Science Center; Hesham M Elgouhari, MD, Hepatology/Transplant Hepatology Fellow, Cleveland Clinic
Contributor Information and Disclosures

Updated: Aug 13, 2008

Differential Diagnoses

Angiosarcoma
Catscratch Disease
Cryptococcosis
Histoplasmosis
Kaposi Sarcoma
Sporotrichosis

Other Problems to Be Considered

Pyogenic granuloma
Common wart
Hemangioma
Dermatofibroma
Angiokeratoma
Verruga peruana
Infections caused by Mycobacterium haemophilum, Mycobacterium kansasii, and Mycobacterium marinum

Workup

Laboratory Studies

  • Bacillary angiomatosis in patients with who are also infected with HIV most commonly causes anemia, leukopenia, and CD4+ cell counts of less than 0.2 X 109/L. In a series of 42 patients with bacillary angiomatosis, the average CD4+ cell count was 0.021 X 109/L. A rapid drop in hemoglobin level in the absence of bleeding or hemolysis has been reported in a patient with peliosis and was thought to be secondary to the sequestration of blood into pools in a liver or spleen that was massively enlarged. Thrombocytopenia with coagulopathy may also occur with peliosis.
  • Indirect immunofluorescent antibody test to detect antibodies to B henselae has been used to diagnose bacillary angiomatosis. Immunoglobulin (IgG) titers of higher than 1:64 against B henselae suggest bacillary angiomatosis. An enzyme immunoassay for the detection of IgG antibodies to B henselae is now available and is reported to be 5-10 times more sensitive than the indirect fluorescent antibody test.
  • Blood cultures may yield organisms if grown at 35°C in 5% carbon dioxide for 3 weeks using a lysis centrifugation technique. B henselae colonies are rough, cauliflowerlike, and usually deeply embedded in the agar. B quintana colonies are smooth, flat, and shiny and do not pit the agar. Whole cell fatty acid gas chromatography has been used to identify the organisms once they have grown in culture.
  • Culture of Bartonella from solid tissue is more difficult but possible.
  • The diagnosis of cutaneous bacillary angiomatosis and extracutaneous disease is most often based on clinical features coupled with biopsies of lesions and appropriate tissue staining (see Histologic Findings). Detection of Bartonella DNA in tissue specimens by polymerase chain reaction (PCR) or Bartonella antigens by immunohistochemical methods is diagnostic.
  • Elevation of alkaline phosphatase, gamma-glutamyltransferase, and transaminase levels may indicate hepatic involvement. Alkaline phosphatase levels are more markedly elevated (5 times normal on average) than transaminase levels, which are usually mildly to moderately elevated or normal.

Imaging Studies

  • Radiographs of the bones overlying the skin lesions in patients with bacillary angiomatosis may demonstrate simple cortical erosions, osteolytic lesions, extensive cortical destruction, or a periosteal reaction. Bone scan findings are always positive at the site of osseus lesions and may help identify the additional areas of involvement not revealed by conventional radiography.
  • In peliosis hepatis, a CT scan of the liver may demonstrate hypodense ringlike lesions that may enhance with contrast. The absence of mass effect on adjacent vasculature is characteristic. On MRI, the lesions appear bright on T2-weighted images and dark on T1-weighted images. Enhancement patterns of one published MRI case study suggests centripetal enhancement similar to hemangioma, but another MRI case study suggests centrifugal enhancement.
  • Although authors disagree on the characteristic radiologic appearance of peliosis hepatis associated with bacillary angiomatosis, the most common presentation on CT scans consists of low-density lesions, some with peripheral enhancement. Homogeneous hypervascularity and nodular peripheral enhancement are not characteristic and would suggest an alternative pathology.8
  • CT scan of the chest and abdomen may reveal mediastinal, retroperitoneal, or mesenteric lymph node enlargement.
  • In intracerebral bacillary angiomatosis, CT scan of the brain reveals a contrast-enhancing mass lesion.

Procedures

  • Biopsy specimens of skin, subcutaneous or mucosal lesions, or, in cases of peliosis hepatis, the liver, are diagnostic.
  • With gastrointestinal involvement, endoscopic studies may reveal ulcerated nodules of the mucosa of the stomach, small intestine, or large intestine.
  • With lung involvement, bronchoscopy may reveal polypoid lesions.

Histologic Findings

Histologic examination of skin lesions reveals vascular proliferation involving small blood vessels that contain plump cuboidal epithelial cells interspersed with polymorphonuclear inflammatory cell infiltrates and clumps of granular purple material. Coincidental endothelial cell necrosis and cytological atypia may lead to a misdiagnosis of angiosarcoma. Solid areas of spindle cells may also be present, which, in some cases, mimic Kaposi sarcoma or other sarcomas.

Histologic examination of liver sections in peliosis hepatis reveals dilated blood-filled spaces in the fibromyxoid stroma that contain inflammatory cells, dilated capillaries, and clumps of granular purple material.

Histologic examination of lymph nodes reveals coalescing nodules of proliferated small blood vessels, some with prominent endothelial cells, in the cortical and paracortical areas. The uninvolved parenchyma may show follicular hyperplasia, plasmacytosis, or sinus histiocytosis.

Histologic examination of the bone reveals a lobular proliferation of small blood vessels with prominent endothelial cells. Neutrophils may be sparse, and their lobular nature may not be apparent in some bone biopsy findings.

Bacillary angiomatosis lesions of the lymph nodes, bone, and brain may demonstrate a less lobular pattern than cutaneous lesions and have a less prominent neutrophilic infiltrate.

The granular purple material in tissue sections stained with hematoxylin and eosin are masses of bacteria, which can be demonstrated by modified silver staining (Warthin-Starry silver stain) or electron microscopy. However, the major drawback of Warthin-Starry silver stain is lack of specificity.

Other organisms that stain positive with Warthin-Starry silver stain include Legionellae species (Legionnaires pneumonia), Nocardia species (nocardiosis), Trophermyma whippleii (Whipple disease), Afipia felis (catscratch disease), Treponema pallidum (syphilis), Borrelia burgdorferi (Lyme disease), and Helicobacter pylori (chronic active gastritis). However, bacillary angiomatosis is clinically distinguishable from infections caused by these organisms, except for Nocardia brasiliensis.

Transmission electron microscopy reveals clumps of pleomorphic bacilli measuring 0.2-0.5 µm by 1-3 µm that have a trilaminar structure to the cell walls, which is typical of vegetative forms of gram-negative bacilli.

Pseudoepitheliomatous hyperplasia has been described in an immunocompromised patient with AIDS and bacillary angiomatosis.9 Pseudoepitheliomatous hyperplasia is a histologic reaction pattern characterized by epithelial proliferation in response to various stimuli, including mycobacterial, fungal, and bacterial infections. Histologic examination of a finger lesion from this patient demonstrated capillary proliferation with neutrophilic debris and characteristic amorphous granular deposits. Warthin-Starry and Giemsa staining revealed clumps of coccobacilli. PCR using cervical lymph node tissue also revealed Bartonella organisms.

More on Bacillary Angiomatosis

Overview: Bacillary Angiomatosis
Differential Diagnoses & Workup: Bacillary Angiomatosis
Treatment & Medication: Bacillary Angiomatosis
Follow-up: Bacillary Angiomatosis
References
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References

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Further Reading

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Keywords

bacillary angiomatosis, epithelioid angiomatosis, bacillary epithelioid angiomatosis, Bartonella infection, colonic bacillary angiomatosis, osseous bacillary angiomatosis, cutaneous bacillary angiomatosis, CNS bacillary angiomatosis, intracerebral bacillary angiomatosis, AIDS-related angiomatosis, BA, Bartonella species, Bartonella henselae, Bartonella quintana, B henselae, B quintana, angiomatous skin lesion, HIV infection, cat scratch, cat bite, pet injuries, louse bite, lice infestation, lice, body lice

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Contributor Information and Disclosures

Author

KoKo Aung, MD, MPH, FACP, Assistant Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
KoKo Aung, MD, MPH, FACP is a member of the following medical societies: American College of Physicians and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Thwe T Htay, MD, Assistant Professor, Department of Medicine, University of Texas Health Science Center at San Antonio
Thwe T Htay, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Romeo Papica II, MD, Research Associate, Department of Internal Medicine, Texas Tech University Health Sciences Center
Disclosure: Nothing to disclose.

Harvey Kantor, MD, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Texas Tech University Health Science Center
Harvey Kantor, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Illinois State Medical Society, Infectious Diseases Society of America, New York Academy of Sciences, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Hesham M Elgouhari, MD, Hepatology/Transplant Hepatology Fellow, Cleveland Clinic
Hesham M Elgouhari, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society of Transplantation, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Gary L Gorby, MD, Program Director of Adult Infectious Diseases Fellowship, Associate Professor, Department of Internal Medicine, Division of Infectious Disease, St Joseph Medical Center, Creighton University School of Medicine
Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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