History
Patients with bacillary angiomatosis commonly have a history of HIV infection, organ transplantation, leukemia, or chemotherapy. [1] However, it also has been reported in immunocompetent individuals. [10] Inoculation bartonellosis may be evident in immunocompetent individuals as a pyogenic granuloma–like nodule at the site of a cat scratch. [2, 3]
Most patients with bacillary angiomatosis are infected with HIV and have CD4+ cell counts of less than 200/µL (although bacillary angiomatosis can develop prior to HIV seroconversion in some patients). The duration of symptoms before diagnosis usually is several months.
In some cases, bacillary angiomatosis becomes evident or recurs during immune restoration after initiation of highly active antiretroviral therapy (HAART). [31, 32]
Features of skin, subcutaneous, mucosal, and osseous lesions caused by bacillary angiomatosis include the following:
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Raised red or purple lesions in the skin that bleed when traumatized
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Similar lesions in the oral mucosa, tongue, palate, oropharynx, nose, penis, and anus
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Facial tumor and multiple abscesses [35]
Bartonella-related pseudomembranous angiomatous papillomatosis of the oral cavity, seen as vegetating papillomatosis exclusively on the oral mucosa, has been described. [7, 36] Oral lesions may occur without concomitant cutaneous lesions. Oronasal fistula formation has been reported. [37]
Visceral involvement associated with bacillary angiomatosis may be asymptomatic or may cause the following symptoms:
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Fever, chills, malaise, night sweats, anorexia, and weight loss
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Symptoms of peliosis hepatis, including abdominal pain, nausea, and vomiting
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Jaundice secondary to biliary obstruction caused by external compression of periportal lymph nodes
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Intra-abdominal mass and gastrointestinal bleeding
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Symptoms of colonic bacillary angiomatosis, including abdominal cramps, tenesmus, and bloody diarrhea
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Symptoms of CNS bacillary angiomatosis, including psychiatric symptoms, such as exacerbation of depression or new-onset psychosis; personality changes, including anxiety and irritability; headache; trigeminal neuralgia; seizures; and back pain
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Difficulty breathing secondary to laryngeal obstruction
Physical Examination
Skin and subcutaneous lesions
Cutaneous lesions due to bacillary angiomatosis may take one of the following forms:
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Solitary or multiple red, purple, flesh-colored, or colorless papules (hemangiomalike lesions) varying in size from 1 mm to several centimeters. An analysis of 605 healthy people in southern Spain found 13.55% IgG seropositive to B. henselae and 11.07% seropositive to B. quintana, delineating an elevated prevalence of both in this region. [30]
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Nodules, often covered with a fine, tightly adherent scale
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Large, friable, pedunculated, or polypoid exophytic masses
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Hyperpigmented, hyperkeratotic, indurated plaques, typically on the extremities and often overlying osseous defects
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Dermoscopic examination of cutaneous papules and violaceous nodules may show oval shapes with bright red areas and globular structures on a grayish background. Arborizing telangiectasia may be evident in the periphery. [38]
The number of lesions may vary from 1 to more than 1000, and they are often multiple. Multiple lesions often demonstrate more than 1 morphologic appearance. Black patients, in particular, may bear the plaque form.
A 40-year-old HIV-positive homosexual man with lichenoid cutaneous plaques on his upper extremities.
Cutaneous lesions may develop ulceration, discharge, and crusting, and they often are tender. Smaller lesions tend to be covered with an attenuated epidermis, whereas larger lesions tend to erode and bleed. Most lesions are rubbery and firm upon palpation and usually are freely mobile. They may be associated with regional lymphadenopathy. In rare cases, lesions may regress spontaneously.
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 often are tender. The overlying skin may appear normal.
Because extensive visceral bacillary angiomatosis may occur with only cutaneous disease evident, regard skin bacillary angiomatosis as a marker of possible internal involvement.
Mucosal lesions
Mucosal lesions are similar to other lesions and may involve oral, conjunctival, nasal, anal, or penile mucosal surfaces.
Ocular involvement
Ocular involvement in bacillary angiomatosis has been reported in immunocompetent and immunocompromised patients. It can range from eyelid involvement to papillitis, hyalitis, and retrobulbar neuritis. [39, 40]
Visceral involvement
Visceral involvement may lead to fever, abdominal distention, hepatomegaly, and splenomegaly. This involvement eventually may progress to bacteremia and sepsis syndrome. Neurologic deficits may accompany intracranial mass lesions.
Visceral involvement may occur in the absence of cutaneous lesions. In this case, the diagnosis often is delayed, because the manifestations of visceral involvement are nonspecific.
A 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 those without extracutaneous involvement. [41]
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A 35-year-old retrovirus-negative Mexican immigrant who had undergone recent splenectomy for idiopathic thrombocytopenic purpura, with multiple violaceous nodules on his trunk.
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Many blood vessels of varying dimensions lined by swollen endothelial cells that contain bacilli. An infiltrate of acute and chronic inflammatory cells as well as fibrin deposition is noted in places (hematoxylin and eosin, X80).
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A 40-year-old HIV-positive homosexual man with lichenoid cutaneous plaques on his upper extremities.
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Lesion showing large masses of blood vessels of markedly varying dimensions lined by swollen endothelial cells. The tissue is friable with evident fragmentation during processing (hematoxylin and eosin, X23).
