Transcript Bartonella infection in children

Bartonella infection in children
Rabeen Lutchman
Why this talk
O Think outside the box
Structure
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Quick Revision of an Approach to lymphadenopathy
Bartonella:
O Organism and different species
O Etiology and Pathogenesis
O Epidemiology
O Clinical Picture of typical Cat Scratch Disease
O Atypical Presentation
O Diagnosis
O Treatment
Case Presentation
Lymphadenopathy
O Infection, Inflammatory and Malignant
processes
O Generalized – 2 or more non-contagious
lymph nodes groups
O Regional – 1 lymph node group
O Pathological is more than 10mm (15mm
inguinal)
Generalized
Lymphadenopathy
O Viral
EBV, CMV, HIV,
Hepatitis(B,C), Varicella,
Adenovirus, Rubella
O Bacterial
Mycobacterium
Tuberculosis, Treponema
Pallidum (secondary
syphilis), Brucella,
Leptospira interrogans
O Fungal
Histoplasma capsulatum
Coccidioides immitis
O Protozoal
Toxoplasma gondi
Regional Lympadenopathy
O STDs
Neisseria gonorrhoese
Treponema pallidum
Herpes simples virus
Haemophilus ducreyi
Chlamydia trochomatis
O Non Venereal Origin
Bacterial
Staphylococcus aureus
Group A and B Streptococci
Mycobacterium tuberculosis
Bartonella henselae
Yersinia pestis
Sporothrix schenckii
O Viral
EBV
O Protozoal
Toxoplasma gondii
Non infectious
lymphadenopathy
O Congenital
O Inflammatory conditions (JIA, SLE,
Kawasaki’s Disease)
O Malignancy
(leukemia,lymphoma,neuroblastoma)
O Adverse drug reactions (phenytoin, INH,
allopurinol)
Batonella Infection in
Children
Organism
O gram-negative, intracellular, oxidase-
negative, fastidious aerobic rods.
O Warthin –Starry silver impregnation stain or
Brown –Hopps tissue Gram-stain.
Species
Etiology and Pathogenesis
O Cats
O Direct horizontal transmission ✗
O Ctenocephalides felis
O Evasion of the immune system -
intraerythrocytic parasites
O Humans  cat saliva or scratch of a cat.
O Invades CD34 hematopoietic progenitor cells
and not the erythrocytes directly
O Presence and Replication of these organisms
inside erythroid differentiated cells
Response
Immune Competent Host:
O Granulomatous and Suppurative
O Lymphoid hyperplasia and arteriolar
proliferation
O Interferon- y- mediated T helper1 cell response
 macrophage recruitment
O Multinucleated giant cells with central areas of
necrosis
O Microabsesses ± suppuration of the lymph node
O Remains within the lymphatics
O Symptomatic response lasting 2-4 months
Immune Deficient Host:
O Vasoproliferative response
O Bacillary angiomatosis
O Differential : Kaposi’s or pyogenic
granuloma or verruca peruana (B
bacilliformis)
Epidemiology
O Worldwide distribution (not confined to
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developing countries)
Overall seroprevalence in cats in the US 
28 -51%
Disease of children  54- 87% of cases
with CSD being under 18
0.6 per 100 000 children < 18 years
0.86 per 100 000 children < 5 years
High Rate of Bartonella henselae infection in
HIV-positive outpatients in Johannesburg,
South Africa - Frean et al., Trans Royal Soc.
Trop Med. Hyg., 2002;96:549-550
O 188 pts – 19 (10.1%) were PCR positive for B hensaelae
O 1 patient had suspected bacillary angimatosis
O 13 of the 19 were tested serologically and 8/13 (62%)
were seropositive (1:64 or higher)
Clinical Manifestations
Typical Cat Scratch:
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Isolated lymphadenopathy with fever ( ⅓ may present without
fever and <10% have a fever > 39°C)
Erythematous papule - 3 to 10 days after inoculation
Erythematous, vesicular and papular crusted stages
Regional lymphadenopathy  1-3 weeks after inoculation
Lymphadenopathy is seen in all with typical CSD and 85%
have a single node involved – most commonly axillary and
epitrochlear (46%) and the head and neck (26%) and inguinal
(17.5%)
Nodal distribution  contact most commonly with the hands
± 10% of nodes will suppurate  drainage
Non typical or complications of B.
hensalae infection
Pyrexia of unknown origin
O Reported cases 3rd most common
after EBV and osteomyelitis
O ± 30 %hepatosplenic
involvement
O intra abdominal lymphadenopathy with fever and
abdominal pain
O PUO and abdominal pain
Ocular manifestations:
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Neuroretinitis and macular stellate exudate is the most common posterior
segment ocular complication
Stellate macular retinopathy has been associated with several infections
including CSD
Approximately 2/3 of patients with neuroretinitis have positive serological
evidence of previous B. henselae infection
Unilateral or rarely bilateral abrupt loss of vision
Optic disc swelling and macular star formation
Recovery of vision within 2-3 months
Optimal treatment for the neuroretinitis is unknown – doxycycline and
rifampicin in adults for 4-6 weeks good results
Other posterior segment presentations : panuveitis, retinal vasoproliferative
lesions, macular hole, vitreal detachment, retinal white spots and a papilitis
In immunocompromised patients: subretinal mass with an abnormal
vascular network – best seen with fluorescein angiography
Other :
O Encephalopathy
O Haematological
O Hepatosplenic – with abdominal lymphadenopathy and
microabscesses in the spleen (Not all TB!!)
O Dermatological - Bacillary angiomatosis
O Orthopedic – osteomyelitis/osteolytic lesions.
O RF negative arthritis/ arthralgia
(female/adults/erythema nodosum) (mainly
knees/wrist/ankle and elbow joints)
O Pulmonary – atypical pneumonia/ pleural thickening/
effusion
O Pseudomalignancy
Diagnosis
Treatment
O Varies : clinical manifestation and immune
status of the patient
O Paucity of data – most case series rather than
RCA’s
O Divide between in vitro efficacy of antibiotics
and the ability to successfully treat in clinical
practice
O In vitro sensitive to
macrolides/aminoglycosides/ trimethroprimsulphamethoxazole /B lactams and extended
spectrum cephalosporins/ rifampicin and
ciprofloxacin
Single RCA :
Prospective randomized double-blind placebocontrolled evaluation of azithromycin for the
treatment of cat-scratch disease. Pediatr
infect Dis J. 1998;17(6): 447-452
80% decrease in lymph node volume in 50% of AZA
treated patients compared to 7% of the placebo group in
the first 30 days
O No difference in clinical outcome and no efficacy
demonstrated for disseminated disease
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O Aspiration if the suppurate or if chronic
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large painful lymphadenopathy
I and D ✗  chronic sinus tract
formation
Complicated management is guided case
studies rather than RCA’s
For neuroretinitis doxycycline is considered
a preferred drug because of the intraocular
and CNS penetration . Children less than 8 ?
? antibiotic is necessary
Case Study
O 3 year old girl referred from the clinic with
non resolving conjunctivitis not responding
to chloromycetin eye drops
O Seen in Ggr: 1 week history of red eyes,
photophobia and poor vision – walking into
objects
O On examination: lymph nodes palpated in
the anterior chain of cervical region (small
nodes) and (R) red eye
O Referred to opthalmology…
Differential macular star
Workup
HIV Θ
RPR/ FTA Abs Θ
Toxo IgG/IgM Θ
Toxocara canis IgG Elisa Θ
ESR 27
ANA Θ
ds DNA Θ
ASOT Θ
CT brain: No features of ICP, Impression of slight optic nerve
swelling ?Neuritis otherwise unremarkable orbits and retro
orbital structures
O LP: cells Θ, Bacteria Θ, VDRL/FTAΘ, Crpto/ CLATΘ
O Bartonella serology pending
Rx: Azitromycin 5 days and Bactrim for 6 weeks
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References
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Todd et al. Beyond cat scratch disease: widening spectrum of
Bartonella henselae infection. Pediatrics May 2008;
121(5):e1413-1425
Tsukahara et al. Bartonella henselae infection as a cause of
fever of unknown origin. Journal of Clinical
Microbiology.2000,38(5):1990-1991
Ahmad M et al.Seroprevalence of Bartonella henselae and
Bartonella quintana infections in children from Central and
Northern Jordan Saudi Med J 2004; Vol.25(11): 1664-1669
Bass et al. Prospective randomized double-blind placebocontrolled evaluation of azithromycin for the treatment of
cat-scratch disease. Pediatr infect Dis J. 1998;17(6): 447452
Frean et al. High Rate of Bartonella henselae infection in
HIV-positive outpatients in Johannesburg, South Africa. Trans
Royal Soc. Trop Med. Hyg., 2002;96:549-550