Elsevier

Clinics in Dermatology

Volume 28, Issue 5, September–October 2010, Pages 483-488
Clinics in Dermatology

Skin diseases associated with Bartonella infection: Facts and controversies

https://doi.org/10.1016/j.clindermatol.2010.03.003Get rights and content

Abstract

The genus Bartonella is composed of a series of species and subspecies. Ten of them are responsible for human infections. The best-identified diseases are cat scratch disease (B henselae and possibly B clarridgeiae), trench fever (B quintana), bacillary angiomatosis (B quintana and B henselae), and the spectrum of verruga peruana, Carrion disease, and Oroya fever (B bacilliformis). Controversies exist about the implication of a few other microorganisms being involved in these diseases. Several other conditions have been associated with the presence of Bartonella spp, but these observations await confirmation.

Introduction

The bacteria family Bartonellaceae, genus Bartonella has expanded during the past century from the recognition of the single Bartonella bacilliformis to 19 recognized species and subspecies (Table 1). Ten of these microorganisms, including B bacilliformis, B henselae, B quintana, B elizabethae, B clarridgeiae, and B vinsonii arupensis, have been found to be responsible for human infections.1, 2, 3 The growing knowledge in this field of pathology and new insights provided by molecular biology suggest that the number of recognized Bartonella spp and human diseases caused by them are likely continue to increase in the coming years.4

Bartonella spp are gram-negative bacteria that appear as small, curved, and pleomorphic rods. A characteristic feature of these microorganisms is their adherence to and invasion of erythrocytes. This phenomenon depends on the erythrocyte species of origin. Another unique facet of infection with Bartonella spp is their ability to promote angiogenesis, presumably by causing endothelial cell proliferation and migration.5, 6, 7, 8, 9, 10Bartonella spp are often cultivable, but this procedure is highly fastidious. The currently available methods for analyzing their genetic and protein compositions allow precise molecular characterization.4, 11 The spectrum of clinical illnesses varies with the nature of the Bartonella spp pathogen. In addition, the clinical features can be surprisingly variable among patients infected with the same species.12, 13

This contribution focuses on the cutaneous manifestations of bartonelloses, emphasizing some controversial topics about angiomatous skin lesions.

Section snippets

Past and ongoing controversies

The group of bartonelloses encompasses diseases without any single typical sign in common. The bacteria are hardly seen at standard microscopic inspection, and microbiologic culture is quite difficult to perform with confidence. In addition, a given Bartonella spp can cause different clinical diseases, depending on the host, geography, and climatic conditions controlling the presence of specific animal reservoirs and vectors. Socioeconomic status and war conditions also influence the nature and

Cat scratch disease

Cat scratch disease (CSD) is the most common Bartonella infection worldwide.1 In patients with history of a cat scratch, a bite of a cat's flea (Ctenocephalides felis), or a tick bite,14 the disease typically presents as a prominent swelling of lymph nodes draining from the arms (cervical, axillary, or epitrochlear). This presentation is preceded by an erythematous papule at the inoculation site.15, 16, 17 The cutaneous lesion develops 7 to 15 days after inoculation and usually evolves through

Trench fever

In the past century, trench fever has been one of the most widespread bartonellosis. Transmitted by the human body louse (Pediculus humanus), the disease became rare after World War II but surged again during the last decades in poor, homeless, alcoholic men living in urban areas.49, 50, 51 This disease, caused by B quintana, follows a cyclic clinical evolution associating relapsing fever, malaise, chills, anorexia, sweating, headache, conjunctivitis, severe myalgias, and arthralgias. About 80%

Bacillary angiomatosis

The first case of bacillary angiomatosis (BA) was associated with AIDS.52B henselae and B quintana were identified in the cutaneous lesions and blood of affected individuals using culture and polymerase chain reaction amplification of specific gene sequences.53 AIDS-associated BA was most frequently seen when the CD4 lymphocyte counts decreased to fewer than 100 cells/mm.54, 55, 56 BA was also reported in immunocompromised cardiac and renal transplant patients,57 in patients receiving

Verruga peruana, Carrion disease, and Oroya fever

B bacilliformis, the etiologic agent of verruga peruana, was the first identified member of the Bartonella genus. The disease presents as an eruptive angiomatous disease of the skin that typically develops 2 months after an acute phase of bacteriemia known as Oroya fever or Carrion disease. In addition to the regular presentation of the angiomatous lesions,72, 74, 75, 76, 77, 78, 79 atypical aspects have been identified.80 There is some histologic similarity between verruga peruana and BA that

Miscellaneous bartonelloses

Quite recently, Bartonella spp have been implicated in a variety of disorders.83, 84, 85, 86 Among them, Kikuchi disease, some granulomatous disorders, and Henoch-Schönlein purpura have been considered in the field of dermatology. They await confirmation by other observations.

Skin and the immune system in bartonelloses

The skin-restricted features of verruga peruana and the predominant skin manifestations in BA, together with the immunologic impaired status found in both diseases, make it attractive to suggest a common pathobiologic pathway.3 The skin might be a target of specific microorganisms responsible for angiomatous diseases in the setting of impaired immune function. The statement that Bartonella-associated vascular lesions may represent angiogenic responses calls for further research.5 The ability of

Conclusions

Bartonella spp infections are responsible for a series of distinct clinical presentations, including vascular growths in the skin. The cellular and molecular components of BA and verruga peruana lesions should be scrutinized. Some analogy among these diseases could provide evidence for common biologic mechanisms. Further research must seek the identification of the whole spectrum of the pathogens, in particular, the Bartonella spp responsible for vascular tumors.

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