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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Opportunistic Infections>
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Peliosis hepatis

Andrea Cox, M.D., Ph.D., Christopher J. Hoffmann M.D., M.P.H.
05-18-2009

  • Bartonella spp. described in ticks, canines and felines in many African locales, so clearly endemic.
  • Little literature in either HIV+ or non-HIV+ patients in Africa. Most described disease from North Africa/Mediterranean regions, and these are of endocarditis, not bacillary angiomatosis or peliosis hepatis.
  • One study in S. Africa suggested 10% of their HIV clinic had Bartonella bacteremia (see Frean J, et al. reference). Unclear if this is representative.

REFERENCES

Zambia Information Author: Paul Auwaerter, M.D.

PATHOGENS

  • Definition: blood filled cavities (lakes) in liver that develop through Bartonella-induced neo-angiogenesis. Often accompanied by peliosis in the spleen.
  • Causes: in HIV+ pts usually caused be infection by Bartonella spp. In HIV-negative (and some HIV+) pts, caused by anabolic steroids, Castleman's disease, Hodgkin's lymphoma, leukemia, other malignancies including hepatic tumors
  • Pathogens: Bartonella henselae and B. quintana (formerly known as Rochalimea henselae and R. quintana)
  • B. henselae: linked to cat and flea exposure
  • B. quintana: linked to homelessness, low-income, and lice exposure
  • Small, fastidious, gram-negative aerobic bacilli

CLINICAL

  • Occurs at low CD4 counts; usually <100 
  • May be associated with immune reconstitution inflammatory syndrome (IRIS) and higher CD4 count during reconstitution 
  • Characterized by multiple, small, dilated blood-filled cavities in hepatic & splenic parenchyma.
  • Sx: indolent course of fevers, nausea, abdominal pain, & malaise.
  • PE: hepatosplenomegaly, 10-30% may also have bacillary angiomatosis
  • Lab: alk phos 5-10 x ULN, ALT & AST may be 2x ULN; thrombocytopenia & pancytopenia have been reported
  • Rarely may cause hypovolemic shock in HIV+ pts due to hepatic hemorrhage.

DIAGNOSIS

  • Blood Cxs rarely positive for Bartonella, Cx sensitivity increases with use of isolator tubes or tubes containing EDTA; specific lab conditions required to enhance yield, so notify lab of suspicion for Bartonella infection.
  • Definitive Dx by isolating organism from Cx of blood or tissue. Warthin-Starry silver staining shows masses of small, dark staining bacteria. staining, PCR, and serology findings.
  • Abdominal CT: hepatomegaly +/- splenomegaly with hypodense lesions scattered throughout liver parenchyma. Other conditions producing similar radiographic findings: lymphoma, disseminated MAC, hepatic KS, and extrapulmonary pneumocystosis.
  • Serologic methods (based on studies of cat scratch disease [CSD]): IFA and EIA. IFA IgG titer <1:64 suggests no infection;1:64 - 1:256 suggests possible infection;>1:256 suggests active or recent infection. Repeat testing in 10-14 days for titers suggesting possible infection. HIV and low CD4 associated with decreased probability of seropositivity. Anti-B. henselae IgM recently shown to be useful in Dx of CSD.
  • Given presence of Ab titers to B. henselae of >1:256 in 4.8% of healthy controls (Sander Aet al. ref.) and lower likelihood of detectable Abs with low CD4 (Mohle-Boetani JC et al. ref.), PCR may be more useful in pts with AIDS. Can distinguish between Bartonella spp.   

TREATMENT

Antibiotic

Drug Comments

DrugRecommendations/Comments
Erythromycin Drug of choice.
Doxycycline Preferred alternative to erythromycin
Rifampin Add to erythromycin or doxycycline in pts with severe illness, but be aware of drug interactions with ARV agents.
Azithromycin Only anecdotal support for use of macrolides other than erythromycin.
Ciprofloxacin Only anecdotal & in vitro support for use

Pathogen Specific Therapy

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