Seronegative disseminated Bartonella spp. infection in an immunocompromised patient

Claudia Weilg, Olguita Del Aguila, Fernando Mazulis, Wilmer Silva-Caso,3, Carlos Alva-Urcia, Rosario Cerpa-Polar, Erick Mattos-Villena, Juana Del Valle Mendoza,3?

1Medicine School, Research Center and Innovation of the Health Sciences Faculty, Universidad Peruana de Ciencias Aplicadas, Lima, Peru2Pediatric Service, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru3Molecular biology laboratory, Instituto de Investigación Nutricional, Lima, Peru4Pediatric Hematology Service, Hospital Edgardo Rebagliati Martins, Lima, Peru

Seronegative disseminated Bartonella spp. infection in an immunocompromised patient

Claudia Weilg1, Olguita Del Aguila2, Fernando Mazulis1, Wilmer Silva-Caso1,3, Carlos Alva-Urcia1, Rosario Cerpa-Polar2, Erick Mattos-Villena4, Juana Del Valle Mendoza1,3?

1Medicine School, Research Center and Innovation of the Health Sciences Faculty, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
2Pediatric Service, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
3Molecular biology laboratory, Instituto de Investigación Nutricional, Lima, Peru
4Pediatric Hematology Service, Hospital Edgardo Rebagliati Martins, Lima, Peru

ARTICLE INFO

Article history:

Received 17 July 2016

Received in revised form 18 August 2016

Accepted 17 September 2016

Available online 16 November 2016

Bartonellaspp.

An 11 year old, hispanic girl with a history of B-cell acute lymphoblastic leukemia was dmitted to the hospital for symptoms compatible withBartonella henselaeinfection. The first molecularly diagnosed case of disseminatedBartonella henselaeinfection was reported in an mmunocompromised patient in Lima, Peru. The analysis was confirmed by Polymerase Chain Reaction and automated sequencing of a liver biopsy sample, even though the serologic tests were negative. In conclusion,Bartonellaspp. infection should have a particular diagnostic onsideration in immunocompromised patients with fever of unknown origin and further nvestigation regarding the patient’s past exposures with cats should also be elicited.

1. Introduction

Bartonellaspp. is a genus that includes facultative, intracellular, gram-negative bacteria with the potential to cause prolonged intraerythrocytic bacteriemia in mammals[1]. Analysis of the 16 s rRNA gene has allowed a phylogenetic reorganization of the genus identifying between 30 and 40 species[2,3]. The main species pathogenic to humans areBartonella henselae(B. henselae),Bartonella B. quintanaandBartonella bacilliformis(B. bacilliformis), all of which are etiologies to a series of diseases such as Cat’s Scratch Disease, Trench Fever, Chronic Lymphadenopathy, Endocarditis, Hepatic Peliosis and Carrion’s disease[4].

We report an unusual presentation ofBartonellaspp. infection with hepatic, splenic and renal involvement, diagnosed by PCR in a seronegative immunocompromised patient.

2. Case report

An 11 year old, hispanic girl with a history of B-cell acute lymphoblastic leukemia (B-ALL) came to the emergency department with a history of hyporexia, asthenia, nausea, vomiting, fever and myalgias that had begun 2 weeks earlier. The patient did not report any abdominal pain and neither rashes nor lymphadenopathies were evidenced during the exam. The patient’s hometown is Tingo Maria in Huanuco, a rural central region in Peru. Her household had access to basic services and her family reported they had two cats, a dog, a hamster and a parrot at home. A monthbefore presentation, the patient received induction chemotheraphy IA for B-cell acute lymphoblastic leukemia with Citarabine, Dexamethasone and Methrotexate; however, the induction IB was delayed due to a septicemia by positive Klebsiella pneumonia ESBL. On physical examination, the patient was wielding a Port catheter. She did not appear under distress and did not appear toxic. Further examination revealed an axillary temperature of 38.2 ℃, blood pressure 110/65 mmHg, a heart rate 120 bpm. Examination of the lungs, heart and abdomen were normal. No lymphadenopathies, skin rashes or hepatosplenomegaly were evident.

A complete blood count evidenced leukocytosis with 22.21×103cells/mL and 90% neutrophils. She had a hemoglobin of 9.5 g/dL and her platelets were at 299×103. C-reactive protein was elevated at 13.46 mg/dL. Her liver function tests, creatinine and urea were within normal limits.

Blood and urine cultures were repeatedly negative during the patient’s hospital stay. Blood samples cultured for fungi, and Tuberculosis were negative. Cultures from the Porth catheter were ordered, but came back negative. Moreover, serologic tests for Cryptococcus neoformans, Histoplasma capsulatum, TORCH, Hepatitis B virus, HIV andB. henselaewere also negative.

An abdominal Computerized tomography (CT) was ordered revealing hypodense lesions in the liver, spleen and kidneys (Figure 1A, 1C, 1E). The lesions in the liver measured 3.3 cm in segment VI and 2.1 cm in segment Ⅷ as opposed to the diffuse distribution of the lesions found in the spleen and kidney that measured between 0.9 cm and 1.6 cm. The CT also revealed bilateral axillary adenopathies. A liver biopsy was ordered and the results showed a filiform distortion with a complete disruption of the arquitecture composed of cicatricial tissue with both an acute and chronic inflammatory process. The liver samples were histochemically stained with Gram, Ziehl-Neelsen, Giemsa and periodic acid Schiff, all of which came back with negative results.

The biopsy specimen was sent to the Molecular Laboratory at the Intitute of Nutritional Research in Lima-Peru for a molecular study. DNA was extracted from the sample and the 16S rRNA gene fromBartonellaspp. was amplified following the conditions described by del Valleet al[14]. The results were positive and the diagnosis of disseminatedBartonellaspp. infection was established (Figure 2). Henceforth, the antibiotic treatment with Vancomicin, Meropenem and Caspofungin, initiated based on a clinical suspicion of bacteremia or fungemia, was suspended and replaced with a daily course of Azithromycin.

The patient’s clinical condition improved gradually with the new antibiotic regimen. The fever decreased and the patient no longer reported myalgias, nausea or vomiting, even though hyporexia persisted. A follow-up Abdominal CT scan was ordered after a 26 day-course of antibiotic treatment with Azithromycin had begun and it showed a significant reduction in the size and number of the lesions in the liver, spleen and kidneys (Figure 1). The patient continued with a favorable clinical course. Eventually she was discharged with stable clinical conditions and was later followed up to continue the induction therapy for LLA-B.

Figure 1. Computer tomography before and after the treatment.

Figure 2. Conventional PCR of 16S Bartonella spp. for the patient’s sample.

3. Discussion

Bartonellaspp. are responsible for a worldwide distribution ofzoonotic infections[5]. The clinical course varies from a self limited infection byB. henselae[6], to fatal cases seen in patients infected byB. bacilliformiswhere mortality rates can reach 85% if left untreated[7]. In Peru, the incidence ofB. bacilliformisinfection is 12, 7/100 person-years, and it increases to 38/100 person-years in children below the age of 5[8].B. henselaeinfection is also reported and it mainly affects the population below the age of 21[9], although no local studies on prevalence have been published.

The main reservoir forB. henselaeis the domestic cat with asymptomatic bacteremia even though transmission has also been reported from dogs[10,11]. On the other hand, humans are the only reservoir forB. quintanaandB. bacilliformis[12]. The transmission for most of the species in theBartonellagenus is through direct contact or via insect vectors.B. henselaecan be transmited by a cat’s scratch, bite or cat flea[13], as is suspected for our patient’s case due to the history of two household cats. In contrast, transmission ofB. bacilliformisrequires a phlebotomus mosquito of the genus Lutzomya[13].Bartonellaspp. infects erythrocytes and vascular endothelial cells by means of a flagellum causing intraerytrhocytic bacteremia[14].B. henselaeaids this process by inhibiting lysosomal fusion and acidification after it has been phagocyted[13].

Bartonellaspp. infections have a more disseminated presentation in immunocompromised patients as reported in cases with HIV infection[15], LES[16], oncological diagnoses[17] or post-transplanted individuals[18-21]. These patients generally have a dermatologic component with violaceous cutaneous lesions and a visceral component with bacillary angiomatosis[22-24]. Furthermore, bacteremia, bacillary peliosis, splenitis and osteomyelitis can also develop[25,26].

In our case report, the patient had a diagnosis of ALL-B and her immunity was further suppressed with induction therapy. This may explain the resulting hepatosplenic and renal involvement.

The gold standard for the diagnosis ofB. henselaeis serology[27]. Assays forB. henselaecan detect IgM and IgG and may support the clinical diagnosis. Sensitivities vary between 14%-100% for IgG and 2%-50% for IgM whereas the specificities are 34%-100% and 86%-100% respectively[6].

Cross-reactivity with other microorganisms may contribute to false positives and also, these tests may be inaccurate in immunocompromised patients due to a diminished antibody response[28]. The latter may explain the persistent seronegativity evidenced in our patient. Amplification of the 16s rRNABartonellagene via PCR is an alternative molecular diagnostic test with higher sensitivities and specificities reported[4]. In our seronegative patient, this method was essential for the etiologic diagnosis ofBartonellaspp. infection under the suspicion of fever of unknown origin, and for the consequent adjustment of treatment suspending unnecessary antibiotics.

IDSA guidelines recommend treatment with Azithromycin for cat scratch disease affecting skin and soft tissue[29], however definite treatment for disseminatedBartonellaspp. infection has not been established[30]. A cohort studied the efficiency certain antibiotics for Cat Scratch disease in immunocompetent patients[31] but to our knowledge a study evaluating antibiotic efficiency for disseminatedBartonellaspp. infection in immunocompromised patients, has not been published. Appropriate treatment is paramount in these patients due to the likelihood of a complicated disseminated infection that may lead to a critical condition or death.

This study presents the first reported case in Peru of molecular identification ofBartonellaspp. via PCR of a hepatic tissue specimen from an immunocompromised patient diagnosed with LLA-B and seronegative on multiple occasions forB. henselae.

In conclusion,Bartonellaspp. infection should have a particular diagnostic consideration in immunocompromised patients with Fever of Unknown Origin and further investigation regarding the patient’s past exposures with cats should also be elicited. In this case, the definitive diagnosis was made by a molecular technique after serology came back negative, stressing the importance of PCR in a complicated and rare presentation ofBartonellaspp. infection. Prolonged treatment with Azithromycin alone proved effective in this patient, however there is a need for consensus on the treatment for immunocompromised patients.

Conflict of interest statement

We declare that we have no conflict of interests.

[1] Siamer S, Dehio C. New insights into the role ofBartonellaeffector proteins in pathogenesis.Curr Opin Microbiol2015; 23: 80-85.

[2] Kosoy M, Hayman DT, Chan KS.Bartonellabacteria in nature: where does population variability end and a species start?Infect Genet Evol2012;12(5): 894-904.

[3] Angelakis E, Didier R. Pathogenicity and treatment ofBartonellainfections.Int J Antimicrob Agent2014; 44(1): 16-25.

[4] del Valle Mendoza J, Silva Caso W, Tinco Valdez C, Pons MJ, del Valle LJ, Casabona Oré V, et al. Diagnosis of Carrion’s disease by direct blood PCR in thin blood smear negative samples.PLoS One2014; 9(3): e92283.

[5] Breitschwerdt EB, Maggi RG, Chomel BB, Lappin MR. Bartonellosis: an emerging infectious disease of zoonotic importance to animals and human beings.J Vet Emerg Crit Care2010; 20(1): 8-30.

[6] Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch disease: widening spectrum ofBartonella henselaeinfection.Pediatrics2008; 121(5): e1413-1425.

[7] Maguina C, Garcia PJ, Gotuzzo E, Cordero L, Spach DH. Bartonellosis (Carrión's disease) in the modern era.Clin Infect Dis2001; 33(6): 772-779.

[8] Chamberlin J, Laughlin LW, Romero S, Solórzano N, Gordon S, Andre RG, et al. Epidemiology of endemicBartonella bacilliformis: a prospective cohort study in a Peruvian mountain valley community.J Infect Dis2002; 186(7): 983-990.

[9] Lamps LW, Scott MA. Cat-scratch disease: historic, clinical, and pathologic perspectives.Am J Clin Pathol2004; 121(Suppl): S71- S80.

[10] Keret D, Giladi M, Kletter Y, Wientroub S. Cat-scratch disease osteomyelitis from a dog scratch.J Bone Joint Surg Br1998; 80(5): 766-767.

[11] Rojas N, Troyo A, Castillo D, Gutierrez R, Harrus S. Molecular detection ofBartonellaspecies in fleas collected from dogs and cats from Costa Rica.Vector Borne Zoonotic Dis2015; 15(10): 630-632.

[12] Angelakis E, Raoult D. Pathogenicity and treatment ofBartonellainfections.Int J Antimicrob Agent2014; 44(1):16-25.

[13] Mosepele M, Mazo D, Cohn J.Bartonellainfection in immunocompromised hosts: immunology of vascular infection and vasoproliferation.Clin Dev Immunol2012; 2012: 612809.

[14] Minnick MF, Mitchell SJ, McAllister SJ. Cell entry and the pathogenesis ofBartonellainfections.Trends Microbiol1996; 4(9): 343-347.

[15] Favacho A, Roger I, Akemi AK, Pessoa AA Jr, Varon AG, Gomes R, et al. Molecular identification ofBartonella henselaein a seronegative cat scratch disease patient with aids in Rio de Janeiro, Brazil.Rev Inst Med Trop Sao Paulo2014; 56(4): 363-365.

[16] Vargas-Hitos JA, Sabio JM, Navarrete-Navarrete N, Arenas-Miras Mdel M, Zamora-Pasadas M, Jiménez-Alonso J. Cat scratch disease in an immunosuppressed patient with systemic lupus erythematosus.Lupus2016; 25(3): 310-311.

[17] Mazur-Melewska K, Jo czyk-Potoczna K, Mania A, Kemnitz P, Szyd?owski J, S?u ewski W, et al. The significance ofBartonella henselaebacterias for oncological diagnosis in children.Infect Agent Cancer2015; 10: 30.

[18] Psarros G, Riddell J 4th, Gandhi T, Kauffman CA, Cinti SK.Bartonella henselaeinfections in solid organ transplant recipients: report of 5 cases and review of the literature.Medicine (Baltimore)2012; 91(2): 111-121.

[19] Gai M, d’Onofrio G, di Vico MC, Ranghino A, Nappo A, Diena D, et al. Cat-scratch disease: case report and review of the literature.TransplantProceed2015; 47(7): 2245-2247.

[20] Rostad C, McElroy AK, Hilinski JA, Thompson MP, Drew CP, Denison AM, et al.Bartonella henselae-mediated disease in solid organ transplant recipients: two pediatric cases and a literature review.Transplant Infecti Dis2012; 14(5): E71-E81.

[21] Picascia A, Pagliuca C, Sommese L, Colicchio R, Casamassimi A, Labonia F, et al. Seroprevalence ofBartonella henselaein patients awaiting heart transplant in Southern Italy.J Microbiol Immunol Infect2015. doi: 10.1016/j.jmii.2015.05.001.

[22] Moulin C, Kanitakis J, Ranchin B, Chauvet C, Gillet Y, Morelon E, et al. Cutaneous bacillary angiomatosis in renal transplant recipients: report of three new cases and literature review.Transplant Infect Dis2012; 14(4): 403-409.

[23] Psarros G, Riddell J 4th, Gandhi T, Kauffman CA, Cinti SK.Bartonella henselaeinfections in solid organ transplant recipients.Medicine2012; 91(2): 111-121.

[24] Orsag J, Flodr P, Melter O, Tkadlec J, Sternbersky J, Hruby M, et al. Cutaneous bacillary angiomatosis due toBartonella quintanain a renal transplant recipient.Transplant Int2015; 28(5): 626-631.

[25] Chang C, Lee CJ, Ou LS, Wang CJ, Huang YC. Disseminated cat-scratch disease: case report and review of the literature.Paediatr Internat Child Health2016; 12: 1-3.

[26] Graveleau J, Grossi O, Lefebvre M, Redon H, Caignon JM, Pallardy A, et al. Vertebral osteomyelitis: an unusual presentation ofBartonella henselaeinfection.Semin Arthritis Rheum2011; 41(3): 511-516.

[27] Metzkor-Cotter E, Kletter Y, Avidor B, Varon M, Golan Y, Ephros M, et al. Long-term serological analysis and clinical follow-up of patients with cat scratch disease.Clin Infect Dis2003; 37(9): 1149-1154.

[28] La Scola B, Raoult D. Culture ofBartonella quintanaandBartonella henselaefrom human samples: a 5-year experience (1993 to 1998).J Clin Microbiol1999; 37(6): 1899-1905.

[29] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America.Clin Infect Dis2014; 59(2): e10-52.

[30] Prutsky G, Domecq JP, Mori L, Bebko S, Matzumura M, Sabouni A, et al. Treatment outcomes of human bartonellosis: a systematic review and meta-analysis.Int J Infect Dis2013; 17(10): e811-e819.

[31] Margileth A. Antibiotic therapy for cat-scratch disease.Pediatr Infect Dis J1992; 11(6): 474-478.

ment heading

10.1016/j.apjtm.2016.11.001

Claudia Weilg, Medicine School, Health Sciences Faculty, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.

?Corresponding author: Juana del Valle Mendoza, Universidad Peruana de Ciencias Aplicadas-UPC, Av. Primavera 2390, Monterrico, Lima, Peru.

Tel: +5113133333 ext 2704

Fax: +5113496025

E-mail: jdelvall@upc.edu.pe

Foundation project: It was partially supported by the Programa Nacional de Innovación para la Competitividad y Productividad (Innóvate Perú), under the contract 117-PNICP-PIAP-2015.

Bartonella henselae

B-cell acute lymphoblastic leukemia Peru