eMedicine Specialties > Infectious Diseases > Bacterial Infections

Bartonellosis

Kassem A Hammoud, MD, Fellow, Department of Internal Medicine, Division of Infectious Diseases, University of Kansas Medical Center
Daniel Hinthorn, MD, Director, Division of Infectious Diseases, Professor, Departments of Internal Medicine, Pediatrics and Family Medicine, University of Kansas; Brian Edwards, MD, Consulting Staff, Department of Infectious Diseases, Cotton O'Neil Clinic

Updated: Oct 13, 2008

Introduction

Background

Bartonellosis comprises infections caused by newly emerging pathogens in the genus Bartonella. In 1909, A. L. Barton described organisms that adhered to RBCs. The name Bartonia, later Bartonella bacilliformis, was used for the only member of the group identified before 1993. Rochalimaea (named for Rocha-Lima), a similar group, were recently combined with Bartonella. Although these organisms were originally thought to be rickettsiae, Bartonella bacteria can be grown on artificial media, unlike rickettsiae.

At least a dozen species belong to the genus Bartonella. Three Bartonella species are currently considered important causes of human disease, but other significant human pathogens in this genus will undoubtedly be found in the future. In one study, serum specimens from 114 patients hospitalized with a febrile illness were tested with an indirect immunofluorescence assay (IFA) using rodent and human Bartonella pathogens; 5 patients had high-titer seroconversion to rodent-associated Bartonella.¹

B bacilliformis causes Oroya fever and verruga peruana. Bartonella henselae causes catscratch disease (CSD) and peliosis of the liver (often called bacillary peliosis). Bartonella quintana causes trench fever. Both B henselae and B quintana may cause bacillary angiomatosis, infections in homeless populations, and infections in patients infected with HIV.

New Bartonella species that may cause human disease include Bartonella vinsonii, Bartonella clarridgeiae, Bartonella tamiae, Bartonella rochalimae, and Bartonella elizabethae. Several of these other species are found in animals.

For additional information on emerging and reemerging infectious diseases, see Medscape’s Emerging and Reemerging Infectious Diseases Resource Center.

Pathophysiology

B bacilliformis, which uses a polar flagellum for motility, adheres to and invades RBCs. After entry, the organism replicates in vacuoles. This species also makes an endothelial cell–stimulating factor that causes proliferation of both endothelial cells and blood vessels.

B henselae and B quintana do not bind to intact human erythrocytes in the same way that B bacilliformis does; however, these organisms make a protein binder that adheres to feline RBC membranes, and they penetrate into endothelial cells. Both species also initiate production of an endothelial cell–stimulating factor. Because lysis-centrifugation blood cultures show enhanced isolation of B henselae and B quintana, intracellular forms are most likely present in humans. Erythrocytes may serve as a reservoir for Bartonella species.

B quintana also invades endothelial cells and forms bacterial aggregates that are taken internally by the invasome, a unique phagosomal structure.² These proliferate and make intracellular blebs.

Frequency

United States

Catscratch disease caused by B henselae infection occurs in approximately 1 per 10,000 persons.

B quintana is found worldwide and causes febrile outbreaks. Poor sanitation and lack of personal hygiene strongly correlate with transmission by the body louse Pediculus humanus. B quintana is emerging as a recognized cause of disease among homeless persons and persons with AIDS. Trench fever syndrome is found among people with alcoholism and those who are homeless. Persons who are indigent in inner-city Seattle were evaluated for antibodies to B quintana. Approximately 20% of these people had antibody titers of 1:64 or greater; in comparison, this titer was found in only 2% of blood donors.³

International

B bacilliformis transmission is limited to the Andes Mountains at elevations of 1000-3000 meters because of the habitat of the sand fly Phlebotomus, now called Lutzomyia. Outbreaks of B bacilliformis infection occur only in the Andes. Cases elsewhere in the world are found in travelers.

B henselae is found throughout the world in association with both domestic and feral cats. It has recently been reported in cats in Germany. The cat flea Ctenocephalides felis is an arthropod vector. B henselae has been isolated from ticks, but their competence in disease transmission is unclear.^4,5

B quintana infection has been reported in 16% of homeless hospitalized patients in France.

Other species, such as B clarridgeiae, may be a cause of asymptomatic infection in cats.

Mortality/Morbidity

Catscratch disease usually causes self-limited regional adenopathy. Acute hemiplegia has been reported in an 11-year-old boy.⁶ Encephalopathy is the most common neurologic complication but is rare.

B henselae is a common cause of culture-negative endocarditis. Valve replacement is required in approximately 80% of cases, but overall prognosis is good, with survival rates in excess of 80%.⁷ In a 2003 article in Medicine by Houpikian and Raoult, Bartonella endocarditis was associated with B quintana in 75% of cases and with B henselae in 25% of cases. They reported a mortality rate of 7% among 99 patients with Bartonella endocarditis.⁸

Trench fever is a self-limited relapsing febrile illness. Affected persons regularly recover, even without treatment. Liver abscesses and spleen abscesses in the absence of endocarditis in an immunocompetent host have been described.⁹

Disseminated forms of bartonellosis develop in patients infected with HIV. Bacillary angiomatosis and culture-negative endocarditis are caused by B henselae and B quintana. Peliosis hepatis is caused by B henselae.

Carrión disease commonly affects the pediatric population in Peru and Ecuador. Mortality and morbidity of the acute phase vary because of superimposed infections and other complications. Mortality rates associated with the eruptive phase, known as Peruvian wart, are extremely low.¹⁰

Clinical

History

Currently, Bartonella species cause several clinical syndromes, including catscratch disease (with enlarged nodes and other organ involvement), bacteremia, endocarditis, bacillary angiomatosis, peliosis hepatis, Oroya fever, and verruga peruana. The inability to mount an immune response contributes to manifestations observed in immunosuppressed individuals with advanced AIDS and other diseases.

• Catscratch disease
  • Most affected individuals have typical catscratch disease symptoms and present with an enlarged lymph node.
  • A primary inoculation lesion often develops at the site of a bite or scratch.
  • A papule or pustule develops 5-10 days after exposure. This lesion may persist for a few weeks.
  • B henselae DNA may be chronically shed into peripheral blood during the natural course of catscratch disease.¹¹
• Bacteremia and systemic illnesses
  • Trench fever was described in military personnel during World War I. Urban trench fever is now observed in homeless persons in the United States and Europe.
  • Symptoms of trench fever begin with chills and fever after an incubation period of a few days to a month. Occasionally, the patient experiences only a single febrile episode that lasts 4 or 5 days. More commonly, several episodes of fever occur. Each episode lasts about 5 days, which is the origin of the designation quintana. The patient cycles between severe chills and profuse sweating. In other patients, continuous fever lasts 2-6 weeks.
  • Associated symptoms include joint and muscle aches, injected conjunctivae, headache, dizziness, and pain behind the eyes. Some patients have diffuse symptoms without fever.
  • Some cases of trench fever become chronic with debility, with or without fever or aching, and occasionally with hyperexcitability.
  • In patients with HIV, infection with either B henselae or B quintana causes gradual onset of aching, headache, fatigue, and weight loss. Fever begins later. Persistent bacteremia with B henselae may develop in people with AIDS.
  • Encephalopathy has been associated mostly with B henselae. Guillain-Barré syndrome, hydrocephalus, and encephalopathy were associated with B quintana acute infection in one case report.¹²
• Bacillary angiomatosis and peliosis hepatitis
  • Bacillary angiomatosis was initially described in persons infected with HIV. Typically, it involved the skin and was believed to resemble Kaposi sarcoma but can affect other organs such as the respiratory tract, bone, lymph nodes, gastrointestinal tract, and brain. When the liver or spleen was involved, bacillary peliosis or peliosis hepatis was diagnosed before Bartonella infection was discovered to be the cause.
  • Symptoms depend on the anatomic site involved and may include fever, tender lymphadenopathy, and skin lesions.
• Oroya fever and verruga peruana
  • Over a century ago, a medical student named Daniel Carrión injected himself with blood from the skin lesion of a patient who had verruga peruana. He developed Oroya fever. Today, Oroya fever and verruga peruana are called Carrión disease. Prior to that time, the relationship between the diseases was unknown.
  • Bacteremia of Oroya fever begins 3-12 weeks after a bite from an infected sand fly. The illness may range from mild to very severe. In severe cases, fever, chills, headache, sweating, aches, dyspnea, mental status changes, and seizure may occur. Severe disease has an abrupt onset.

Physical

• Catscratch disease
  • Enlarged lymph glands develop 1 week to 2 months after exposure. Swollen tender nodes are the usual presenting symptom.
  • Careful examination of the interdigital spaces, skin creases, and scalp increases the chance of finding the primary inoculation lesion. Inoculation sites other than the skin include the eye and mucous membranes (oral ulcer).
  • One third to two thirds of patients develop low-grade fever that lasts several days.
  • B henselae infection is one of the common causes of fever of unknown origin and prolonged fever in children. One study showed that the absence of lymphadenopathy in patients with catscratch disease was closely related to the presence of prolonged fever or systemic complications. Another study of 186 patients with a serological diagnosis of catscratch disease showed that 30 (16.1%) patients had no regional lymphadenopathy. These patients had persistent fever and more frequent systemic complications than patients with lymphadenopathy.¹³
  • Malaise and fatigue are common. Many patients feel healthy except for the enlarged node or nodes. Patients occasionally have multifocal lymphadenopathy.
  • Laboratory studies include the following:
    • Diagnosis should be confirmed with demonstration of a 4-fold rise in antibody levels, initially immunoglobulin M (IgM) followed by immunoglobulin G (IgG).
    • Culture confirmation is difficult; PCR is more sensitive.
    • In some patients, hypercalcemia complicates catscratch disease lymphadenopathy via overproduction of vitamin D due to granuloma formation.
  • Other morbidities include the following:
    • Rarely, catscratch disease spreads and causes granulomatous hepatitis or granulomas in the spleen or bones. Granulomas in the liver or spleen do not enhance with contrast on CT scanning.
    • Parinaud oculoglandular syndrome follows contamination of the eye, often from the patient's own hand. A granulomatous conjunctivitis follows and is associated with enlarged preauricular nodes.
    • Encephalopathy is an infrequent but important manifestation that occurs in as many as 2-4% of patients with catscratch disease. Several hundred such cases probably occur in the United States each year. Manifestations include generalized headaches, restlessness, combativeness, seizure, and neurologic defects such as aphasia, cranial nerve palsy, Brown-Sequard syndrome, and ataxia. Persistent intellectual impairment has been reported. Cerebral spinal fluid (CSF) cultures and routine studies are not helpful in diagnosis.
    • In neuroretinitis caused by B henselae, a sudden loss of eyesight may be the presenting symptom. The patient usually has a prior flulike syndrome or enlarged nodes. A common examination finding is papilledema with a starburst appearance. A recent report described a 10-year-old girl with catscratch disease who developed a macular hole 12 days after presentation with neuroretinitis in association with a posterior vitreous detachment.¹⁴ Neuroretinitis is usually confirmed based on titers, but, on occasion, retinal biopsy with histopathology may prove helpful. Neuroretinitis usually resolves spontaneously except in immunocompromised patients. Multifocal chorioretinal lesions have also been described.¹⁵
    • Transverse myelitis was described in 3 patients with catscratch diseases.¹⁶ One case report described a 40-year-old patient with chronic vasculitis and polyneuropathy associated with bartonellosis.¹⁷
    • Osteomyelitis is a rare manifestation, occurring in 0.2%–0.3% of patients with catscratch disease. Medical therapy with antibiotics is very effective. Maman et al found that, among 913 patients with catscratch disease, 10.5% had musculoskeletal manifestations (myalgia, arthralgia/arthritis, neuralgia, tendinitis, osteomyelitis).¹⁸
• Bacteremia
  • Findings include injected conjunctivae, nystagmus, hepatosplenomegaly, lymphadenopathy, and a maculopapular rash.
  • Muscles or joints may be tender.
  • Laboratory studies include the following:
    • Patients typically exhibit increased leukocytes with occasional thrombocytopenia or albuminuria. Bacteremia is not usually detected.
    • Patients with prolonged bacteremia may have culture-negative endocarditis because Bartonella species do not grow on standard blood culture media. Special media must be used. B henselae and B quintana infections can cause culture-negative endocarditis. Bartonella alsatica was isolated from the valve of a patient with endocarditis.¹⁹ Most cases of Bartonella endocarditis involve native valves, but infection of prosthetic valves is possible.²⁰
    • Antibody titers are helpful in confirming the diagnosis.
  • As expected, persons with alcoholism and those who are homeless typically develop B quintana endocarditis (75% of cases), while persons with exposure to cats are more likely to harbor B henselae (25% of cases). Other Bartonella species are rarely implicated. Although many children are frequently exposed to cats, even those with catscratch disease rarely develop Bartonella endocarditis.
• Bacillary angiomatosis and peliosis hepatitis
  • Examination findings include purple to red-black, raised, palpable skin lesions.
  • When the liver, lymph node, or spleen is involved, it may be enlarged.
  • Laboratory studies include the following:
    • Patients should undergo HIV antibody testing and CD4⁺ lymphocyte assessment.
    • Patients typically have anemia and elevated levels of serum alkaline phosphatase.
• Oroya fever and verruga peruana
  • Untreated patients have a high case-fatality rate. Survivors may be more susceptible to salmonellosis or toxoplasmosis during the convalescent period.
  • Verruga peruana lesions develop as crops with onset weeks to months later in untreated survivors. These lesions begin as small nodules and subsequently grow. Highly vascular mulaire lesions then form and begin to ulcerate, bleed, and heal via fibrosis over several months. Various stages of small to larger nodules, mulaire lesions, and fibrosis may occur simultaneously.
  • Laboratory studies include the following:
    • Hemolytic anemia, thrombocytopenia, and elevated values on liver function studies are common.
    • Survivors may develop persistent bacteremia.

Causes

• Catscratch disease
  • In the United States, catscratch disease is the most common type of bartonellosis.
  • The clinical syndrome has been recognized for more than a century, but the etiology of this condition was confirmed only in the past decade. Confirmation involved isolating Bartonella species from cats and their fleas, showing an antibody titer rise in patients with the disease, and demonstrating the presence of organisms in biopsy samples through culture and PCR.
  • Occasional cases are negative for B henselae antibodies. In these instances, rare causes of catscratch disease such as B clarridgeiae or Afipia felis should be considered.
• Bacteremia may occur with either B henselae or B quintana infection and may result in disseminated diseases. Other species of Bartonella have occasionally been associated with bacteremia.
• Oroya fever and verruga peruana are manifestations of B bacilliformis infection. These diseases are not found in the United States, but they are common in the Peruvian Andes. Verruga peruana is characterized by subcutaneous nodules consisting of neovascularization, somewhat similar to bacillary angiomatosis.

Differential Diagnoses

Bacillary Angiomatosis
Catscratch Disease

Other Problems to Be Considered

Catscratch disease: Consider other causes of enlarged lymph nodes, such as localized infections with regional node swelling and systemic diseases. Examples include lymphoma, leukemia, other neoplasms, fungal infection, tularemia, tuberculosis, plague, lymphogranuloma venereum (LGV), AIDS, and syphilis.

Bacteremia and systemic illnesses: Culture-negative endocarditis is always difficult to diagnose. Consider this diagnosis when the Duke criteria for endocarditis are present with negative findings on routine blood cultures. If bartonellosis is suspected, obtain antibody titers for B henselae and B quintana. Other causes of culture-negative endocarditis that merit consideration include legionellosis, Q fever, HACEK group infections (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), and fastidious or slowly growing streptococci.

Bacillary angiomatosis: These lesions are often dark purple and resemble Kaposi sarcoma, pyogenic granuloma, or verruga peruana.

Oroya fever and verruga peruana: Febrile patients who have returned from travel to a developing country mandate consideration of a rather large number of possible illnesses depending on the itinerary, activities, and potential for exposures. Serious illnesses to consider include Dengue fever, malaria, tuberculosis, and babesiosis.

Workup

Laboratory Studies

• Stains
  • Microscopic examination of Giemsa-stained blood smears is used to detect B bacilliformis in patients who may have Oroya fever.
  • Organisms are rod-shaped and slightly curved, similar to Campylobacter or Helicobacter species.
  • B bacilliformis organisms often appear to be adherent to erythrocytes, but they may actually be inside erythrocytes.
  • Other Bartonella species are visible only with silver stains (eg, Warthin-Starry, Steiner, Dieterle), if they stain at all. Bacillary forms also exist.
  • Immunostaining can also aid in the diagnosis of early lesions or atypical manifestations of catscratch disease.
  • Late in the course of B henselae infection, organisms may not be found in areas of necrotizing granulomas.
• Cultures
  • Culture for Bartonella bacteria is not recommended for routine cases of patients with catscratch disease lymphadenopathy.
  • Cultures may be useful in patients who have other manifestations of either B henselae or B quintana infection, including fever of unknown origin, neuroretinitis, encephalitis, culture-negative endocarditis, and peliosis or bacillary angiomatosis. Fresh media is required to increase the chance of isolation.
  • A recent study suggests a novel chemically modified liquid medium that supports the growth of 7 Bartonella species.²¹
  • The lysis-centrifugation system (Isolator) is recommended for blood cultures.
  • Minced tissues may be cultured on chocolate agar plates in a humid atmosphere with carbon dioxide to facilitate growth.
  • Antibiotic susceptibility is not routinely tested in patients with bartonellosis because susceptibility studies may fail to predict response to therapy.
• Serologic testing
  • Serologic testing is the most cost-effective method to confirm the diagnosis in most patients with bartonellosis; however, serologic testing can provide negative results or can be otherwise nondiagnostic in immunocompromised patients.
  • For catscratch disease and CNS or eye infections, serologic testing provides helpful data. Cross-reactions occur between antibodies for B henselae and B quintana and with both Chlamydia species and Coxiella burnetii.²²
  • Recent studies have shown that Western immunoblotting appears to have very high sensitivity and specificity for diagnosing Bartonella endocarditis.⁸
  • An IgM titer of 1:16 or greater is usually considered evidence for early recent Bartonella infection. IgM levels may stay elevated for about 3 months in 50% of patients.
  • An IgG titer of greater than 1:256 is considered evidence of current or past Bartonella infection. Titers of 1:64 to 1:128 are considered equivocal. A titer of 1:800 or more for IgG antibodies to either B henselae or B quintana has a positive predictive value of 0.810 for the detection of chronic bartonellosis in the general population and a value of 0.955 for the detection of bartonellosis among patients with endocarditis.²³
  • Patients with delayed decreases in antibody titers may be at risk for endocarditis relapse. When clinical suspicion is high, titers should be repeated in 10-14 days for comparison.
  • Evidence shows that some patients never mount a detectable antibody response. The serology results of some patients remain positive long after exposure and recovery from their illness.
• Polymerase chain reaction
  • PCR is a molecular technique that involves amplification of Bartonella species genes.
  • PCR-based detection of various target genes of Bartonella species in tissue specimens is widely accepted in diagnosing catscratch disease and bacillary angiomatosis, but the results rely heavily on the quality of the laboratory in which the assays are conducted.
  • In cases of suspected Bartonella endocarditis, PCR on cardiac valve tissue is very sensitive and is not affected by antibiotics treatment prior to surgery.
  • Because of the cross-reactivity between Bartonella species and other bacteria, PCR analysis of tissue and body fluid is the most specific test, especially in identifying distinct genotypes among Bartonella species.
  • PCR has played an important role in the diagnosis of Bartonella endocarditis. This test amplifies a 296–base-pair fragment of the 16S ribosomal RNA. Investigators reported PCR results that were positive for Bartonella on cardiac valve tissue in more than 95% of patients with Bartonella endocarditis in one study, despite the fact that more than 60% of these patients underwent valve analyzation following the receipt of antibiotics.

Imaging Studies

• CT scanning of the chest and abdomen may reveal mediastinal, retroperitoneal, or mesenteric lymph node enlargement.
• CT scanning or ultrasonography of the abdomen can demonstrate multiple hypodense lesions in the liver and/or spleen in patients with catscratch disease
• In patients with bacillary angiomatosis/peliosis, CT scanning or MRI of the involved organ shows the enhancing lesions (eg, brain, liver). Radiography of the bone may show osteolytic lesions and bone destruction.
• According to some reports, patients with catscratch disease may require echocardiography to assess for valvular lesions. Patients with valvulopathy and catscratch disease are at risk for Bartonella endocarditis.

Other Tests

• The catscratch disease skin test is helpful. However, this test may transmit other infectious agents, as it is derived from human pus.
• Silver stains and PCR can be performed on pus collected from a node via fine-needle aspiration, sparing the patient a surgical biopsy.

Histologic Findings

Catscratch disease: Lymph node biopsy demonstrates granulomas with stellate necrosis, which are characteristic of catscratch disease. Silver stains, such as Dieterle or Warthin-Starry, may show bacilli.

Bacillary angiomatosis and peliosis hepatitis: Both of these disorders show blood vessel proliferation. Bacillary angiomatosis refers to vascular tumors that readily bleed when cut. The microscopic appearance of neovascular proliferation is diagnostic. Silver stains may demonstrate clusters of Bartonella bacilli. Peliosis refers to blood-filled cystic lesions that may be microscopic or up to a few millimeters in diameter. These lesions are characteristically found in the liver but are occasionally found in the spleen. Bacilli may be visible on electron microscopy.

Treatment

Medical Care

• Catscratch disease
  • Several therapies have been successful. Whether therapy should be provided at all is unclear because catscratch disease is ordinarily a self-limited condition that lasts weeks to months. Therapy is typically provided because of patient concerns about tender nodes and because early treatment is believed to reduce the possibility of disseminated complications.
  • Cost-effective pharmaceutical choices include erythromycin or doxycycline. Azithromycin has been shown to be more effective than placebo in resolving lymphadenopathy; some consider azithromycin to be the drug of choice.
  • If the initial therapeutic choice appears unsuccessful after 2-3 weeks, consider switching to azithromycin, co-trimoxazole, or a quinolone antibiotic. Neither penicillins nor cephalosporins (other than third-generation cephalosporins) are active against these organisms. Rifampin in combination with another drug, or the use of gentamicin, may be considered.
  • The usual duration of therapy is 3-6 weeks. Patients who are bacteremic require at least 4 weeks of therapy. Patients with HIV and other immunocompromising diseases require more prolonged therapy. Patients who have vegetations due to bartonellosis often require valve replacement. At least initially, an aminoglycoside should be included in the treatment of endocarditis.²⁴
  • No definitive therapeutic study of CNS bartonellosis or neuroretinitis has been performed, but treating these patients seems prudent. Agents that penetrate the CNS or eye are favored, including doxycycline or azithromycin possibly with rifampin, clarithromycin, or a newer fluoroquinolone antibiotic. A combination of 2 drugs is favored because this may speed healing and because no single agent has been found to cure all cases in which it was used. Data from the literature do not support the use of corticosteroids.
• B quintana infection: For bacteremia or trench fever, patients should be administered a trial of doxycycline 100 mg orally twice daily for at least 4 weeks. A longer duration of therapy should be considered in immunocompromised patients. In addition, when the liver or other organs are involved, the duration of therapy is typically longer.
• Bacillary angiomatosis
  • In persons with AIDS and bacillary angiomatosis, the primary pharmaceutical choices include erythromycin, doxycycline, or more expensive drugs such as azithromycin, clarithromycin, or a fluoroquinolone.
  • Doxycycline combined with rifampin is effective in patients with severe disease. Such patients often require extended treatment (≥3 mo).
• B bacilliformis infection
  • Chloramphenicol has been established as therapy in developing countries, but doxycycline could be used.
  • Duration of therapy should be at least 1 week, and longer courses may be required.

Surgical Care

In an editorial entitled "Bartonellosis: light and shadows in diagnostic and therapeutic issues" in Clinical Microbiology and Infection (2005), Manfredi et al wrote, "The role of surgical debridement and the unpredictable activity of antimicrobial agents warrant further investigation." The authors go on to point out that "The need for, selection and duration of antimicrobial therapy for CSD remain contentious. Suppurative nodes that become tense and painful should be drained, but incision of non-suppurative lesions should be avoided, as chronic draining fistulae or compromised healing may result."²⁵

Consultations

• Infectious diseases specialist
• Possible consultation with a surgeon for biopsy or drainage

Medication

Bartonellosis is generally treated with macrolides, tetracyclines, aminoglycosides, or chloramphenicol. Chloramphenicol is not usually used to treat either B henselae or B quintana infection, although it has been used to treat B bacilliformis infection. Chloramphenicol has been primarily used to treat Oroya fever.

Duration of therapy is commonly at least 3 weeks. Patients should be monitored for evidence of response and drug toxicity. Because these infections often fail to respond to therapy or patients experience relapse later, switching to antibiotics from other classes (eg, erythromycin, clarithromycin, azithromycin, trimethoprim and sulfamethoxazole, or ciprofloxacin) may be needed. Gentamicin may also be effective.

Longer duration of therapy, from 3 weeks to 2 months, may be required for patients who have peliosis hepatis or disseminated disease, including bacteremia.

A culture-negative endocarditis treatment regimen should include an aminoglycoside (gentamicin) for 2 weeks and ceftriaxone with or without doxycycline for 6 weeks.

If bartonellosis is proven, the guidelines recommend using a regimen consisting of doxycycline for 6 weeks plus gentamicin (1 mg/kg IV q8h for 14 d).

Valve replacement is required in approximately 80% of cases, but overall prognosis is good, with survival rates of 80%.

Patients in the acute phase of Carrión disease should receive ciprofloxacin and, alternatively, chloramphenicol plus penicillin G. Patients in the eruptive phase of the disease should receive rifampin and, alternatively, azithromycin or erythromycin.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting.

Doxycycline (Vibramycin)

Inhibits protein synthesis and bacterial growth by binding to 30S, and possibly 50S, ribosomal subunits of susceptible bacteria. For B quintana infection, bacillary angiomatosis, peliosis hepatitis, and AIDS.

Dosing

Adult

Asymptomatic B quintana bacteremia: 100-200 mg PO qd for 15 d; longer duration of therapy may be needed

Pediatric

<8 years: Not recommended
>8 years: Not established

Interactions

Bioavailability decreases minimally with antacids that contain aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives; half-life decreases with coadministration of barbiturates, phenytoin, carbamazepine, rifampin, and ethanol; increases cyclosporine concentration

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

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

Precautions

Photosensitivity occurs in rare cases; reduce dose in renal impairment; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth

Erythromycin (EES, E-Mycin, Eryc)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

Erythromycin base or equivalent: 250 mg PO qid
Erythromycin ethyl succinate: 400 mg PO qid

Pediatric

Erythromycin ethyl succinate: 30-50 mg/kg/d PO qid

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, 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; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, diarrhea, or abdominal colic occur

Azithromycin (Zithromax)

Treats mild-to-moderate microbial infections.

Dosing

Adult

Day 1: 500 mg PO
Days 2-5: 250 mg PO qd; may need to repeat if symptoms do not resolve

Pediatric

Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d

Interactions

May increase toxicity of theophylline, warfarin, 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; coadministration with pimozide

Precautions

Pregnancy

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

Precautions

Bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function; may prolong QT interval; caution in hospitalized, geriatric, or debilitated patients

Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

IR: 250-500 mg PO bid
ER: 500-1000 mg PO qd

Pediatric

IR: 7.5 mg/kg PO bid

Interactions

Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; cardiac arrhythmia may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmia and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents

Contraindications

Documented hypersensitivity; coadministration with pimozide or cisapride

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; superinfections may occur with prolonged or repeated antibiotic therapies

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against Pseudomonas species, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

500-750 mg PO bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

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

Adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing

Adult

160 mg TMP/800 mg SMZ 1 SS tab PO bid

Pediatric

<2 months: Do not administer
>2 months: 5 mL/kg susp PO bid

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

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

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation

Chloramphenicol (Chloromycetin)

Binds to 50S ribosomal subunits and inhibits bacterial growth by hindering protein synthesis. Effective against gram-negative and gram-positive bacteria.

Dosing

Adult

50 mg/kg/d PO/IV divided q6h

Pediatric

Administer as in adults

Interactions

Coadministration with barbiturates may cause chloramphenicol serum levels to decrease, while barbiturate levels may increase and cause toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity

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

Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 3 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, or anemia; caution in pregnancy at term or during labor because of potential toxic effects on fetus (ie, gray syndrome)

Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and another agent that covers anaerobes.

Dosing

Adult

1-2 mg/kg IV/IM q24h; usually reserved for very ill patients or for those who have not responded to initial therapy or have relapsed

Pediatric

Administer as in adults

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, possibly prolonging respiratory depression; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly) with prolonged very high serum levels

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

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

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patient not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Follow-up

Deterrence/Prevention

• B bacilliformis and B quintana infections: Prevention is best achieved by avoiding the circumstances in which exposure to their arthropod vectors occurs. B bacilliformis transmission is limited to the AndesMountains at elevations of 1000-3000 meters because of the habitat of the sand fly Phlebotomus, now called Lutzomyia. Outbreaks occur only in the Andes. B quintana is found worldwide and causes febrile outbreaks. Poor sanitation and lack of personal hygiene strongly correlate with transmission by the body louse Pediculus humanus.
• B henselae infection: B henselae is found throughout the world in association with both domestic and feral cats. Prevention is achieved by avoiding interactions with cats that might result in scratches, bites, or licks, especially kittens, cats with fleas, and cats that are allowed outdoors.

Prognosis

• Catscratch disease rarely results in neurologic sequelae. Adenopathy persists for 6-24 months in 20% of patients. After several months, the lesions of visceral organs calcify or resolve.
• Trench fever is a nonlethal and self-limiting disease, although relapses and chronic bacteremic states are well known.
• Bartonella endocarditis has caused fatalities and usually requires surgical repair. Of 22 cases reported by Raoult and colleagues in 1996, 19 patients underwent valvular surgery, and 6 patients died.²⁶
• Immunocompromised patients with bacillary angiomatosis or peliosis hepatis respond well to antibiotics. Relapse may occur.

Miscellaneous

Medicolegal Pitfalls

• In immunocompetent patients, consider catscratch disease antibody testing during lymphadenopathy evaluation.
• Obtain specimens for Bartonella culture or serologic tests in patients with culture-negative endocarditis.
• Consider bartonellosis in the differential diagnoses of immunocompromised patients with hepatosplenomegaly.

Special Concerns

• Remember serologic cross-reactivity exists among Bartonella, Coxiella, and Chlamydia species.
• Avoid incision and drainage of catscratch disease nodes. Thin-needle aspiration of node is preferred for diagnosis.

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Keywords

bartonellosis, Bartonella infection, catscratch disease, cat scratch disease, CSD, catscratch fever, cat scratch fever, trench fever, urban trench fever, bacillary angiomatosis, bacillary peliosis, peliosis hepatis, Parinaud oculoglandular syndrome, Parinaud's oculoglandular syndrome, Oroya fever, Carrión disease, Carrión’s disease, verruga peruana, Bartonella bacilliformis, B bacilliformis, Bartonella henselae, B henselae, Bartonella quintana, B quintana, Bartonella vinsonii, B vinsonii, Bartonella clarridgeiae, B clarridgeiae, Bartonella elizabethae, B elizabethae, Bartonella tamiae, B tamiae, Bartonella rochalimae, B rochalimae, Bartonella alsatica, B alsatica, Pediculus humanus, P humanus, Phlebotomus, Lutzomyia, Ctenocephalides felis, C felis, Bartonella endocarditis, Peruvian wart

Contributor Information and Disclosures

Author

Kassem A Hammoud, MD, Fellow, Department of Internal Medicine, Division of Infectious Diseases, University of Kansas Medical Center
Kassem A Hammoud, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Hinthorn, MD, Director, Division of Infectious Diseases, Professor, Departments of Internal Medicine, Pediatrics and Family Medicine, University of Kansas
Daniel Hinthorn, MD is a member of the following medical societies: American Academy of Family Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Brian Edwards, MD, Consulting Staff, Department of Infectious Diseases, Cotton O'Neil Clinic
Disclosure: Nothing to disclose.

Medical Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
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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