Approach Considerations
Bacillary angiomatosis can be cured in most patients with antibiotics, so recognition of the disease is critical. Treatment recommendations are based on retrospective studies or clinical observations. A systematic review found that current clinical practice for the treatment of bartonellosis, including bacillary angiomatosis, mostly relies on expert opinion and antimicrobial susceptibility data. [49] No antibiotics have been studied prospectively or in randomized controlled trials. Corticosteroid, cytotoxic, and radiation therapy are not effective. [49] Antiretroviral therapy is essential in HIV-infected individuals. Immune reconstitution inflammatory syndome, complicated by Jarisch-Herxheimer reaction, was reported after antiretroviral therapy and doxycycline. [32]
The reader is referred to the 2014 guidelines published by the Infectious Diseases Society of America (IDSA) for the treatment of bacillary angiomatosis (see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America). [5]
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
Consultations can include the following:
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Infectious diseases specialist
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Dermatologist
Long-term monitoring
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.
Antibiotic Therapy
Clinical experience strongly favors the use of erythromycin or a tetracycline derivative in the treatment of bacillary angiomatosis. Erythromycin remains the drug of choice because it yields an excellent clinical response in almost all patients. (An antiangiogenic effect by erythromycin has been postulated and tested with in vitro models of B quintana infection. [50] )
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 are not effective against bacillary angiomatosis in vivo. Penicillins and cephalosporins have no activity against Bartonella species despite in vitro susceptibilities. The following antibiotics have produced good clinical responses when combined with either doxycycline or ciprofloxacin:
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Clarithromycin
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Azithromycin
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Chloramphenicol
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Ciprofloxacin
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Trimethoprim-sulfamethoxazole
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Rifampin
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Isoniazid
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Gentamicin
These antibiotics have been used successfully in limited numbers of patients. However, treatment failures with ciprofloxacin, trimethoprim-sulfamethoxazole, isoniazid, and rifampin have been reported. [51, 28] Doxycycline is contraindicated in pregnancy.
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 that skin lesions be treated for 8-12 weeks and osseous and liver lesions for at least 3 months, although these treatment periods 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. In one patient with a mass as large as 12 cm in diameter, the lesion completely resolved except for mild residual scarring after 9 weeks of azithromycin, along with antiretroviral therapy for HIV infection. [52]
Prevention
Prevention of bacillary angiomatosis associated with B henselae infection includes avoidance of contact with cats and control of flea infestations in cats.
Preventive measures associated with B quintana infection are as follows:
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Delousing procedures, such as the use of permethrin dusting powder (1%; 30-50 g per adult)
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Treatment of clothing and bedding
In addition, macrolides for Mycobacterium avium-intracellulare prophylaxis in patients infected with HIV are protective against bacillary angiomatosis.
A study by Lappin et al indicated that the risk of B henselae infection in cats via contact with the flea Ctenocephalides felis can be reduced with the use of a flea and tick collar containing 10% imidacloprid and 4.5% flumethrin. In the 8-month trial, cats infected with B henselae and exposed to C felis were housed with a group of uninfected cats who wore flea collars during the trial period and another group of uninfected cats who received no preventive treatment. [53]
The 3 groups were separated from each other by mesh, preventing the cats from having physical contact with members of the other groups but allowing the fleas to move among the groups and, potentially, transmit B henselae to the uninfected cats. Four out of 7 of the cats who received no treatment tested positive by the end of the study for B henselae, whereas none of the cats treated with flea collars were positive for the bacterium.
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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).
