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Disease Categories > Infectious Disease > Bacteria

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Bartonella Species

Bartonella species are the cause of several different diseases, including cat scratch disease.

Epidemiology

B. henselae
- Prevalence – 22,000 infections per year; most common in warm, humid climates during autumn and winter
- Transmission – usually cats
  - Children younger than 1 year have the greatest rate of transmission
  - Transmitted between cats via cat flea, but not to humans
  - Most afflicted patients do not recall being scratched by a cat
B. quintana
- Prevalence – generally low; however, increasing incidence in homeless populations in U.S. and Europe
- Transmission – body louse (Pediculus humanus corporis)

Organism

Bartonella is a gram-negative bacillus that can adhere to and invade mammalian cells
Bartonella species are associated with 4 primary clinical syndromes:
- Bacillary angiomatosis (BA) (B. quintana, B. henselae)
- Bacillary peliosis hepatitis (B. henselae)
- Relapsing fever with bacteremia (trench fever) (B. quintana)
- Cat scratch disease (B. henselae, B. clarridgeiae)

Risk Factors

B. henselae
- Rough play with cats, especially kittens
- Unwashed cat bites and scratches
- Allowing cats to lick open wounds
- Fleas
B. quintana
- Immunocompromised persons (HIV in particular)
- Homelessness
- Alcoholism

Clinical Presentation

B. henselae
- Immunocompetent host
  - Common presentations
  - A localized papule (which progresses to a pustule) develops 3-5 days after cat scratch
  - Tender regional lymphadenopathy develops 1-2 weeks later
    - Cervical and axillary are the most common
  - Secondary bacterial superinfection of involved nodes is not uncommon
  - Other manifestations (less common) – encephalitis, hepatitis, osteomyelitis and disseminated infection
  - Uncommon presentation
    - Conjunctival inoculation may cause Parinaud oculoglandular syndrome with conjunctivitis and periauricular lymphadenopathy
- Immunocompromised host
  - Bacillary angiomatosis
    - Nontender firm red-purple colored skin lesions
      - Dissemination to organs if not treated
  - Bacillary peliosis
    - Vasoproliferation within the liver and spleen
      - Blood-filled cysts with possible organisms in the cysts (identified with Warthin silver stain)
B. quintana
- Trench fever
  - Relapsing fever with bacteremia
  - Sudden onset headache, meningitis and relapsing fever
  - Relapses common when short course antibiotics are used
  - May cause endocarditis
- Bacillary angiomatosis
  - Many organs may be affected – liver, spleen, bone marrow, lymph nodes
  - Hallmark symptoms are vascular nodules and papules or tumors, with proliferation of new blood vessels (angiogenesis)
  - Lesions, termed epithelioid angiomatosis, resemble Kaposi sarcoma

Diagnosis

B. henselae
- Pathologic examination and culture of involved nodes
  - Warthin – starry silver stain
- Laboratory testing
  - Paired sera for antibody testing (70-90% positive in immunocompetent patients)
  - PCR from whole blood, tissue, or CSF
B. quintana
- Trench fever
  - Gold standard test is blood culture, but serology helpful
- Bacillary angiomatosis
  - Diagnosis based on histopathologic findings of angiomas associated with tiny clumps of bacilli by Warthin-Starry silver stain
- Blood cultures are necessary if endocarditis is suspected

Differential Diagnosis

Cat Scratch disease
- Lymphoma
- Kikuchi-fujimoto disease (histocytic necrotizing lymphadenitis)
- Mycobacterium avium-intracellulare
- Toxoplasma gondii (toxoplasmosis)

Sporothrix schenckii

Trench Fever
- Brucella
- Sepsis
  - Bacterial or viral meningitis
- Francisella tularensis
- Rickettsia
Bacillary angiomatosis
- Pyogenic granuloma
- Hemangioma
- Subcutaneous tumors
- Cat scratch disease
  - Cellulitis
  - Mononucleosis
- Kaposi sarcoma

Treatment

B. henselae
- Central nervous system involvement or other serious disease must be treated
B. quintana
- Prolonged course of antibiotic treatment required

Indications for Ordering

Tests generally appear in the order most useful for common clinical situations
Click on number for test-specific information in the ARUP Laboratory Test Directory

Test Name and Number	Recommended Use	Limitations	Follow Up
Bartonella henselae (Cat Scratch) Antibodies, IgG & IgM by IFA 0050108 Method: Indirect Fluorescent Antibody	Order when current or past exposure to B. henselae suspected		If test results equivocal, repeat testing in 10-14 days may be helpful
Bartonella quintana Antibodies, IgG & IgM by IFA 0050106 Method: Indirect Fluorescent Antibody	Identify Bartonella quintana as disease pathogen (70-90% of patients)	False-negatives may occur in HIV/AIDS patients Bartonella quintana antibodies may be cross-reactive with: Bartonella vinsonii and Bartonella henselae Some of the Rickettsial organisms Approximately 50% of typhus group (Rickettsia prowazekii and Rickettsia mooseri) Approximately 66% of scrub typhus (Orientia tsutsugamushi) Rarely cross-reactive with sera from spotted fever group organisms (Rickettsia rickettsii and Rickettsia akari) Bartonella quintana antibodies may be seen in patients with bacillary angiomatosis and/or parenchymal bacillary peliosis	If test results are equivocal, repeat testing in 10-14 days Low positive IgG result suggests past exposure or infection; high positive result may indicate current or recent infection but not conclusively While IgM antibodies suggest recent infection, low IgM levels may occasionally persist >12 months post-infection Best evidence of infection is significant change on 2 appropriately timed specimens, where both tests are performed in same laboratory at same time
Bartonella DNA Detection by PCR, Whole Blood 0060762 Method:	Rapid test for whole blood Use with antibody tests Clarify negative antibody test results in symptomatic patients In epidemiological situations, determine Bartonella species (sequencing of PCR product)	A negative result does not rule out the presence of Bartonella spp DNA in quantities below the sensitivity of assay or the possibility of PCR inhibitors in samples Unidentified sequence variations within the htrA gene of Bartonella may lead to a false-negative result
Bartonella DNA Detection by PCR 0093057 Method: Polymerase Chain Reaction	Rapid test for serum, plasma, CSF or tissue Use with antibody tests Clarify negative antibody test results in symptomatic patients In epidemiological situations, determine Bartonella species (sequencing of PCR product)	A negative result does not rule out the presence of Bartonella spp DNA in quantities below the sensitivity of assay or the possibility of PCR inhibitors in samples Unidentified sequence variations within the htrA gene of Bartonella may lead to a false-negative result
Immunohistochemistry Stain Offering Arup005 Method: Immunohistochemistry	Detect Bartonella quintana in angiomas For fixed tissue samples, consultative services as well as immunohistochemical staining for B. henselae are available
Blood Culture 0060102 Method: Bactec® 9240, continuous monitoring system. Standard reference procedures for identification of aerobic and anaerobic microorganisms	Time-sensitive test Use in patients with endocarditis to determine presence of Bartonella species
Tissue Culture (Includes Gram Stain 0060101) 0060127 Method: Standard reference procedures for bacterial stain, aerobic culture, and identification. Anaerobe culture performed on properly collected specimens.	Time-sensitive test Specify Bartonella as species of interest

Additional Tests Available

Click on number for test-specific information in the ARUP Laboratory Test Directory

Test Name and Number	Comments
Bartonella henselae Antibody, IgG by IFA 0050091 Method: Indirect Fluorescent Antibody
Bartonella henselae Antibody, IgM by IFA 0050092 Method: Indirect Fluorescent Antibody
Bartonella quintana Antibody, IgG by IFA 0050094 Method: Indirect Fluorescent Antibody
Bartonella quintana Antibody, IgM by IFA 0050093 Method: Indirect Fluorescent Antibody

General References

Brouqui P, Raoult D. Arthropod-borne diseases in homeless. Ann N Y Acad Sci. 2006;1078:223-235. (Link to PubMed)

Chomel BB, Kasten RW, Sykes JE, Boulouis HJ, Breitschwerdt EB. Clinical impact of persistent Bartonella bacteremia in humans and animals. Ann N Y Acad Sci. 2003;990:267-278. (Link to PubMed)

Chomel BB, Boulouis HJ, Maruyama S, Breitschwerdt EB. Bartonella spp. in pets and effect on human health. Emerg Infect Dis. 2006;12(3):389-394. (Link to PubMed)

Comer JA, Paddock CD, Childs JE. Urban zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vector Borne Zoonotic Dis. 2001;1(2):91-118. (Link to PubMed)

English R. Cat-scratch disease. Pediatr Rev. 2006;27(4):123-128. (Link to PubMed)

Foucault C, Brouqui P, Raoult D. Bartonella quintana characteristics and clinical management. Emerg Infect Dis. 2006;12(2):217-223. (Link to PubMed)

Karem KL, Paddock CD, Regnery RL. Bartonella henselae, B. quintana, and B. bacilliformis: historical pathogens of emerging significance. Microbes Infect. 2000;2(10):1193-1205. (Link to PubMed)

Lamps LW, Scott MA. Cat-scratch disease: historic, clinical, and pathologic perspectives. Am J Clin Pathol. 2004;121 Suppl:S71-S80. (Link to PubMed)

Raoult D, Foucault C, Brouqui P. Infections in the homeless. Lancet Infect Dis. 2001;1(2):77-84. (Link to PubMed)

Rolain JM, Brouqui P, Koehler JE, Maguina C, Dolan MJ, Raoult D. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother. 2004;48(6):1921-1933. (Link to PubMed)

Windsor JJ. Cat-scratch disease: epidemiology, aetiology and treatment. Br J Biomed Sci. 2001;58(2):101-110. (Link to PubMed)

Zeaiter Z, Fournier PE, Greub G, Raoult D. Diagnosis of Bartonella endocarditis by a real-time nested PCR assay using serum. J Clin Microbiol. 2003;41(3):919-925. (Link to PubMed)

References from the ARUP Institute for Clinical and Experimental Pathology®

Litwin CM, Johnson JM. Identification, cloning, and expression of the CAMP-like factor autotransporter gene (cfa) of Bartonella henselae. Infect Immun. 2005;73(7):4205-4213. (Link to PubMed)

Litwin CM, Rawlins ML, Swenson EM. Characterization of an immunogenic outer membrane autotransporter protein, Arp, of Bartonella henselae. Infect Immun. 2007;75(11):5255-5263. (Link to PubMed)

Reviewed by

Carney, Heather, M.D. Assistant Medical Director, Transfusion Services at ARUP Laboratories; Pathology, University of Utah

Hillyard, David R., M.D. Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Associate Professor, Pathology, University of Utah

Litwin, Christine, M.D. Medical Director, Immunology at ARUP Laboratories; Professor, Clinical Pathology, University of Utah

Petti, Cathy A., M.D. Medical Director, Infectious Diseases at ARUP Laboratories; Assistant Professor, Pathology and Medicine, University of Utah

Comprehensive Review: July 2008
Last Update: July 2008