CONTINUING MEDICAL EDUCATION
CASE REPORT

 

Bacillary angiomatosis: A rare finding in the setting of antiretroviral drugs

 

 

M C Madua

MB ChB, FCP (SA); Rob Ferreira Hospital, Nelspruit, South Africa

 

 

---

ABSTRACT

An HIV-positive 39-year-old man presented with generalised nodular lesions. He was apyrexial and normotensive, with a normal respiratory rate. The rest of the examination was normal. He had been on antiretroviral therapy for > 4 years; most importantly, he was on a second-line regimen (lopinavir/ritonavir (Aluvia) based). The appearance of the lesions, together with the history, led to the following possible diagnoses: bacillary angiomatosis, cutaneous cryptococcosis, nodular Kaposi sarcoma or cutaneous histoplasmosis.

---

 

 

An HIV-positive 39-year-old man presented with generalised nodular lesions (Figs 1 - 4). He was apyrexial and normotensive, with a normal respiratory rate. The rest of the examination was normal. He had been on antiretroviral therapy for >4 years; most importantly, he was on a second-line regimen (lopinavir/ritonavir (Aluvia) based). The appearance of the lesions, along with the history, led to the following possible diagnoses: bacillary angiomatosis, cutaneous cryptococcosis, nodular Kaposi sarcoma or cutaneous histoplasmosis.

 

 

 

 

 

 

 

 

Investigations revealed the following:

• absolute CD4 count: 15 x 10⁶/L (500 - 2 010)

• HIV viral load: 1 764 copies/mL

• blood cultures: aerobic and anaerobic -negative

• full blood count: normocytic anaemia, with haemoglobin: 8 g/dL (14.3 - 18.3)

• urea and electrolytes: normal

• liver function test: normal

• calcium, magnesium and phosphate: normal

• urine microscopy culture and sensitivity: negative

• sputum for GeneXpert for tuberculosis: negative

• bone marrow trephine biopsy: multi-factorial cause of anaemia, no obvious infiltrates

• skin biopsy - vascular proliferative lesions in keeping with Bartonella, substantiated by a polymerase chain reaction (PCR)

• tissue culture: no growth

• chest radiography: normal.

A diagnosis of bacillary angiomatosis is clinical and can be confirmed by serology, blood culture and histology.^[1-3] It is difficult to culture Bartonella;^[1-2] serology cannot differentiate between species.^[1,2] Warthin-Starry silver staining is the gold standard for diagnosis, revealing clusters of bacilli.^[1,2]

Vascular proliferative lesions are typical histological features.^[1,2] In our case, however, Warthin-Starry silver staining did not reveal the bacilli; therefore, tissue was sent for PCR testing, which confirmed the diagnosis. Nested PCR yielded 19 positive results from 188 specimens from HIV-positive patients.^[4] After being treated with erythromycin and rifampicin for 1 month, our patient's lesions regressed.

 

Discussion

There are > 30 different species of Bartonella,^[1,2] of which 13 have been isolated in humans.^[1,2] Bartonella species are fastidious, facultative, intracellular, slowgrowing Gram-negative bacteria that cause a broad spectrum of diseases in humans.^[1] The two most commonly associated with HIV are B. quintana and B. henselae.^[1,2,5] Transmission of Bartonella to humans occurs via a cat scratch that is contaminated with Bartonella-infected fleas.^[1,2,5,6] The prevalence of Bartonella in HIV-positive persons is reported to be very low.^[1,2,6] Various organs or systems may be involved in Bartonella infection, ranging from skin, subcutaneous tissue, bones, mucosa, central nervous system, lymph nodes, liver and spleen.^[1,2,7-10] Unspecific manifestations, such as bacteraemia, endocarditis and unexplained fever, have also been reported.^11,2

 

References

1. Longo D, Fauci A, Kasper DL, et al., eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill, 2011.         [ Links ]

2. Goldman L, Schafer AI. Goldman's Cecil Medicine. 24th ed. New York: Saunders, 2012.         [ Links ]

3. Koehler JE, Sanchez MA, Garrido CS, et al. Molecular epidemiology of Bartonella infections in patients with bacillary angiomatosis-peliosis. N Engl J Med 1997;337(26):1876-1883.         [ Links ]

4. Frean J, Arndt S, Spencer D. High rate of Bartonella henselae infection in HIV-positive outpatients in Johannesburg, South Africa. Trans R Soc Trop Med Hyg 2002;96:549-550.         [ Links ]

5. Tappero JW, Perkins BA, Wenger JD, et al. Cutaneous manifestations of opportunistic infections in patients infected with human immunodeficiency virus. Clin Microbiol Rev 1995;8(3):440-450.         [ Links ]

6. Plettenberg A, Lorenzen T, Burtsche BT, et al. Bacillary angiomatosis in HIV-infected patients - an epidemiological and clinical study. Dermatology 2000;201:326-331.         [ Links ]

7. Koehler JE, Quinn FD, Berger TG, et al Isolation of Rochalimaea species from cutaneous and osseous lesions of bacillary angiomatosis. N Engl J Med 1992;327:1625-1631.         [ Links ]

8. Perkocha LA, Geaghan SM, Yen TSB, et al. Clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection. N Engl J Med 1990;323:1586.         [ Links ]

9. Spach DH, Panther LA, Thorning DR, et al. Intracerebral bacillary angiomatosis in a patient infected with human immunodefiency virus. Ann Intern Med 1992;116:740-742.         [ Links ]

10. Mohle-Boetani JC, Koehler JE, Berger TG, et al. Bacillary angiomatosis and bacillary peliosis in patients infected with human immunodeficiency virus: Clinical characteristics in a case-control study. Clin Infect Dis 1996;22:794-800.         [ Links ]

 

 

Corresponding author: M C Madua (chasneyza@yahoo.com)