eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections
Bacillary Angiomatosis: Treatment & Medication
Updated: Aug 13, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
500 mg PO qid
Pediatric
50-100 mg/kg PO divided qid 1 h ac
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
Documented hypersensitivity; hepatic impairment
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.
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
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)
Documented hypersensitivity, coadministration of pimozide
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.
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
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
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
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.
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
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
Documented hypersensitivity; severe hepatic dysfunction; pregnancy; breastfeeding
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.
Adult
300 mg PO q12h
Pediatric
10 mg/kg/d PO, not to exceed 600 mg/d
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)
Documented hypersensitivity
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
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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Further Reading
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
