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

Bacillary Angiomatosis

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
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

Updated: Aug 13, 2008

Introduction

Background

Bacillary angiomatosis (BA) is the vascular proliferative form of Bartonella infection. Bacillary angiomatosis was first described in 1983 in a patient infected with HIV.¹ The disease has since been described in patients following organ transplants and in immunocompromised persons. It is occasionally reported in immunocompetent patients. Initially, bacillary angiomatosis was called epithelioid angiomatosis because of its histologic appearance.

In 1990, Relman et al identified a visible but uncultivable bacillus from affected tissues of patients with bacillary angiomatosis using molecular methods.² They concluded that the unique 16S gene sequence associated with epithelioid angiomatosis belonged to a previously uncharacterized microorganism, most closely related to Rochalimaea quintana. Later, the same organism was recovered in specialized culture media. The gram-negative organism was later named Rochalimaea henselae, and, in 1993, Rochalimaea was reclassified under the genus Bartonella. Bartonella henselae and Bartonella quintana each have been cultured from and detected in bacillary angiomatosis tissues. Bacillary angiomatosis is the second-most-common angiomatous skin lesion in persons infected with HIV.

Pathophysiology

B henselae and B quintana are small gram-negative rods in the family Bartonellaceae. Bartonella, Rickettsia, Ehrlichia, and Afipia species all are part of the alpha-2 subgroup of the Alphaproteobacteria.

Bacillary angiomatosis can affect almost any organ system, although it most commonly affects skin and subcutaneous tissue. Subcutaneous lesions may erode into underlying bones (ie, osseous bacillary angiomatosis), especially the tibia, fibula, and radius. Involvement of ribs and vertebrae has been described. Rarely, skeletal muscles may be involved, resulting in pyomyositis. Mucous membranes of the conjunctiva and upper airway and perineum (anus and penis) may be affected. Bacillary angiomatosis may be accompanied by disseminated visceral disease (peliosis), mainly in the liver (peliosis hepatis), spleen, and lymph nodes.

Other internal organs that may be involved include the brain, bone marrow, heart, lungs, pleura, larynx, oropharynx, tongue, esophagus, stomach, duodenum, colon, peritoneum, diaphragm, kidneys, adrenal glands, pancreas, uterine cervix, and vulva. Extrinsic compression of the common bile duct by enlarged peripancreatic, celiac, and portohepatic nodes has been reported.

The pathogenesis of bacillary angiomatosis includes early blood-borne dissemination of organisms. Bartonella organisms readily attach to and may enter erythrocytes. They avoid opsonization and host phagocytosis by unknown mechanisms and become persistent within the intravascular compartment. An angiogenic factor may be responsible for the vascular proliferation observed in patients with bacillary angiomatosis because a similar factor mediates vasoproliferation in verruca peruana, the second stage of Bartonella bacilliformis infection.

Cutaneous lesions result almost equally from B henselae and B quintana infections. However, subcutaneous and osseous lesions are usually caused by B quintana infection. Visceral involvement is almost exclusively caused by B henselae infection. Neurological disorders are associated more frequently with B quintana infection than with B henselae.

Domestic cats (Felis domesticus) are the reservoirs of B henselae, which may be transmitted via cat bites or scratches or, potentially, by bites from cat fleas (Ctenocephalides felis). Kittens are more frequently associated with transmission of B henselae than older cats. Humans appear to be the only reservoir of B quintana; the human body louse, Pediculus humanus, is the transmission vector.

Frequency

United States

The exact incidence of bacillary angiomatosis is not known. Cases of bacillary angiomatosis have been reported in almost all states, especially in Florida, Texas, New York, and northern California (San Francisco area), areas with a high frequency of HIV infection.

International

Bacillary angiomatosis is reported less commonly in Europe than in North America, which may imply that either diagnoses are missed or that Europe has a minimal reservoir of bacilli. Cases have also been reported in Africa, Peru, and Argentina.

In 2005, an epidemiologic study using serum samples from 253 patients with HIV infection from northern Greece showed that Bartonella infection is much more prevalent among individuals infected with HIV than among healthy individuals in the same area.³

Mortality/Morbidity

The exact mortality and morbidity of bacillary angiomatosis is unknown because the condition was initially described only recently.

Race

Approximately 40% of US patients with bacillary angiomatosis are white, 40% are black, and 20% are of Hispanic origin.

Sex

Approximately 90% of US patients with bacillary angiomatosis are men, probably because a disproportionate number of patients infected with HIV are also men.

Age

Bacillary angiomatosis is extremely rare in children but was reported in a 12-year-old boy with acute leukemia who was undergoing chemotherapy and in a 6-year-old immunocompetent girl.

Clinical

History

• 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.⁴ 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.⁵ Multiple leg ulcers caused by bacillary angiomatosis without a history of direct contact with cats in an adult immunocompetent man has also been reported.⁶

Physical

• 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: These are similar to other lesions and may involve oral, conjunctival, nasal, anal, or penile mucosal surfaces.
• 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.⁷

Causes

• 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

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 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.

Treatment

Medical Care

Bacillary angiomatosis can be cured in most patients with antibiotics, so recognition is critical. Treatment recommendations are based on retrospective studies or clinical observations. No antibiotics have been studied prospectively.

• Clinical experience strongly favors the use of erythromycin or a tetracycline derivative. Erythromycin remains the drug of choice because it yields an excellent clinical response in almost all patients. Tetracyclines are the first alternative in patients who cannot tolerate erythromycin. A combination of doxycycline (100 mg PO/IV q12h) plus rifampin (300 mg PO bid) may be used in immunocompromised patients with severe disease.
• Other antibiotics display in vitro activity, but in vitro susceptibility data do not accurately predict success in vivo. Penicillins and cephalosporins have no activity against Bartonella species despite in vitro susceptibilities. Clarithromycin, azithromycin, chloramphenicol, ciprofloxacin, trimethoprim-sulfamethoxazole, rifampin, isoniazid, and gentamicin combined with either doxycycline or ciprofloxacin produce good clinical responses. These antibiotics have been used successfully in limited numbers of patients. Treatment failures with ciprofloxacin, trimethoprim-sulfamethoxazole, isoniazid, and rifampin have been reported.
• A reaction resembling the Jarisch-Herxheimer reaction has been described upon the initiation of appropriate antibiotic therapy. The reaction is characterized by fever, myalgias, and constitutional symptoms.
• The optimal duration of therapy is not known. Recommendations are based on clinical experience rather than scientific data. Usually, recommendations indicate to treat skin lesions for 8-12 weeks and osseous and liver lesions for at least 3 months, although these have not been studied in prospective randomized trials. Patients with HIV infection may require life-long therapy if relapses occur.
• The cutaneous lesions resolve substantially after approximately 4-7 days of therapy, and they usually resolve completely after 1 month.
• Corticosteroid therapy, cytotoxic therapy, or radiation therapy is not effective.

Surgical Care

Cryotherapy, electrodesiccation and curettage, and surgical excision of solitary cutaneous lesions can be useful as adjunctive therapy. However, antibiotic therapy provides treatment for possible occult dissemination of bacteria, in addition to regression of the lesions.

Consultations

• Infectious diseases specialist
• Dermatologist

Diet

• No special dietary restrictions

Activity

• No restriction of physical activity

Medication

The goals of pharmacotherapy are to eradicate infection, to reduce morbidity, and to prevent complications.

Antibiotics

Empiric antimicrobial therapy should cover all likely pathogens in the context of the clinical setting.

Erythromycin (Ery-Tab, E.E.S., E-Mycin)

Bacteriostatic antibiotic that inhibits bacterial protein synthesis by binding 50S ribosomal subunits.

Dosing

Adult

500 mg PO qid

Pediatric

50-100 mg/kg PO divided qid 1 h ac

Interactions

Coadministration may increase toxicity of theophylline, digoxin, ergotamine, carbamazepine, benzodiazepines, barbiturates, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease and myasthenia gravis; estolate formulation may cause cholestatic jaundice; adverse GI effects are common; discontinue use if nausea, vomiting, malaise, abdominal colic occur; increased QTc interval

Clarithromycin (Biaxin)

Semisynthetic macrolide antibiotic that inhibits bacterial protein synthesis by binding 50S ribosomal subunits.

Dosing

Adult

500 mg PO q12h
ER formulation: 1000 mg PO qd

Pediatric

<6 months: Not recommended
>6 months: 7.5 mg/kg PO divided bid, not to exceed 500 mg PO q12h

Interactions

Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; arrhythmia and increased QTc intervals occur with disopyramide (resulting from increased levels)

Contraindications

Documented hypersensitivity, coadministration of pimozide

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; reduce dose if given with ritonavir in renal impairment; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; caution in breastfeeding

Azithromycin (Zithromax)

Macrolide that inhibits bacterial protein synthesis by binding 50S ribosomal subunits.

Dosing

Adult

Day 1: 500 mg PO
Days 2-5: 250 mg PO q24h

Pediatric

<6 months: Not established
>6 months
Day 1: 10 mg/kg PO once 1 h ac or 2 h pc, not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd 1 h ac or 2 h pc, not to exceed 250 mg/d

Interactions

May increase toxicity of theophylline, warfarin, carbamazepine, phenytoin, ergot alkaloids, triazolam, hexobarbital, cyclosporine, and digoxin; effects are reduced with coadministration of aluminum or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, elderly, or debilitated; monitor for pseudomembranous colitis; caution in breastfeeding

Doxycycline (Vibramycin)

Bacteriostatic antibiotic that inhibits bacterial protein synthesis by binding 30S ribosomal subunits.

Dosing

Adult

100 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 1 mg/kg/d PO/IV divided bid if <45 kg and as in adults if >45 kg

Interactions

Effects decrease with carbamazepine, phenytoin, barbiturates, and antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; may increase digoxin levels; avoid concomitant use with methoxyflurane because of risk of fatal renal toxicity; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction; pregnancy; breastfeeding

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may rarely occur; use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth

Rifampin (Rifadin, Rimactane)

Bactericidal antibiotic that inhibits bacterial protein synthesis by inhibiting DNA-dependent RNA polymerase. Useful in immunocompromised patients with severe disease.

Dosing

Adult

300 mg PO q12h

Pediatric

10 mg/kg/d PO, not to exceed 600 mg/d

Interactions

Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, protease inhibitors, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; concomitant administration with atovaquone increases serum concentration of rifampin and decreases serum concentration of atovaquone; probenecid and trimethoprim-sulfamethoxazole may increase levels; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; caution in breastfeeding

Follow-up

Further Outpatient Care

• For cutaneous lesions, the number and size of the lesions should be monitored to determine the efficacy of treatment.
• For visceral involvement, imaging study findings, hepatic transaminase levels, organomegaly, and/or lymph node enlargement should be monitored to determine response to therapy.

Deterrence/Prevention

• Prevention of bacillary angiomatosis associated with B henselae infection is as follows:
  • Avoid cat contact.
  • Control flea infestations in cats.
• Prevention of bacillary angiomatosis associated with B quintana infection is as follows:
  • Delousing procedures, such as permethrin dusting powder (1%, 30-50 g per adult), can be used.
  • Clothing and bedding should also be treated.
• Use of macrolides for Mycobacterium avium-intracellulare prophylaxis in patients infected with HIV is protective against bacillary angiomatosis.

Complications

• Disfigurement
• Biliary obstruction and jaundice
• Gastrointestinal bleeding
• Encephalopathy
• Laryngeal obstruction and asphyxiation

Prognosis

• The prognosis of bacillary angiomatosis itself is excellent because antibiotics are curative in most patients.
• Untreated bacillary angiomatosis may be progressive and life-threatening.
• The lesions resolve completely after treatment. Hyperpigmentation or slight induration at the site of a lesion may persist indefinitely. Relapses can occur after cessation of therapy and are common in immunocompromised hosts.
• Treatment may be more difficult and requires a longer duration of therapy if the diagnosis is delayed.
• Overall prognosis depends on early detection and treatment and the degree of immunosuppression.

Patient Education

• Immunocompromised patients and their caregivers should be advised to avoid cat contact and to control flea infestations in cats.

Miscellaneous

Medicolegal Pitfalls

• Failure to distinguish Kaposi sarcoma from bacillary angiomatosis may raise legal issues because bacillary angiomatosis, unlike Kaposi sarcoma, responds dramatically to antibiotic therapy. Furthermore, bacillary angiomatosis may be life-threatening if untreated. Bacillary angiomatosis may coexist with Kaposi sarcoma, in which case, the lesions of bacillary angiomatosis may be easily overlooked.

Special Concerns

• Doxycycline is contraindicated in pregnancy.
• Azithromycin can be used in case of intolerance to erythromycin.

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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

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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