Bacillary angiomatosis

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	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

Bacillary angiomatosis

Rachel Nussbaum, M.D., Ciro R. Martins, M.D. & David Kouba, M.D.
03-03-2008

Zambia Specific Information

Bartonella spp. widely distributed and should be considered endemic in Zambia.
No published reports of bacillary angiomatosis in Zambia; has been rarely reported in neighboring countries.
Capacity to make definitive Dx of bacillary angiomatosis in Zambia challenging due to limited Bx, molecular, and microbiology capabilities.
If Dx made, management is as recommended below.

Zambia Information Author: Larry William Chang, MD, MPH

Bartonella spp. are small gram-negative bacilli, formerly called Rochalimea.
Bartonella henselae (most BA, also bacillary peliosis, cat scratch disease, relapsing bacteremia and endocarditis).
Bartonella quintana (some BA, also bacillary peliosis, urban trench fever, endocarditis, and chronic afebrile bacteremia).
Risk factors: immunosuppression; contact with cats; poor living conditions; homelessness; unclear if cat fleas (B. henselae) play a role in transmission of disease. Vector for B. quintana = "body" louse.

Most common with HIV-related immunosuppression (CD4 usually <200), but can also affect transplant recipients, chemotherapy pts, or leukemia pts.
Skin commonly involved with brisk, local vascular proliferation; 2 predominant cutaneous variants: superficial and deep.
Superficial: erythematous to violaceous, friable cutaneous papules or nodules with or without ulceration, usually <1 cm diameter.
Deep: large, skin-colored subcutaneous nodules, several cm in diameter that may ulcerate through epidermis.
Rarely presents as large cellulitic plaque, which may involve bony structures. Extracutaneous spread to any organ possible.
Systemic/hepatic infection (peliosis hepatis): presents with fever, nausea, vomiting, diarrhea, abdominal pain, transaminitis, elevated alk phos; Systemic/splenic infection: presents with pancytopenia.

Clinical DDx: KS, pyogenic granuloma (PG), cherry hemangioma, angiokeratoma, verruga peruana. Histopathologic DDx: KS, PG.
Dx: skin Bx with Warthin Starry silver stain; may Cx on chocolate agar; PCR or RFLP analysis possible to distinguish B.henselae and B. quintana.

Immunocompromised hosts

Preferred: erythromycin 500 mg PO qid x 8 wks.
Alternative: tetracycline 500 mg PO bid x 8 wks.
Other alternatives: clarithromycin, azithromycin, rifampin, ciprofloxacin and doxycycline.
Resistance should be suspected in erythromycin-unresponsive cases
Evidence suggests erythromycin may have both antibacterial and anti-angiogenic effects

Drug	Recommendations/Comments
Azithromycin	In one placebo-controlled study of cat scratch disease, azithromycin associated with more rapid diminution in size of infected lymph nodes.
Ciprofloxacin	In vitro data suggests susceptibility.
Doxycycline	Oral doxycycline used in pts who cannot tolerate erythromycin or tetracycline. Severely ill pts should receive IV doxycycline with either gentamicin or rifampin for at least 4 mos.
Erythromycin	Drug of choice. Problems include potential for cytochrome p450-related drug interactions with antiretrovirals, GI side effects, and qid dosing.
Gentamicin	Severely ill pts should receive IV doxycycline with either gentamicin or rifampin x >4 mos.
Rifampin	Severely ill pts should receive IV doxycycline with either gentamicin or rifampin for x >4 mos.
Tetracycline	May increase risk of photosensitivity. Even darkly pigmented pts should be counseled regarding appropriate photoprotection.

Follow every 2-3 wks, as treatment responses can vary and length of treatment required is substantial.
If lesions persist, consider re-Bx for Cx and sensitivity.

High risk pts (e.g. advanced immunosuppression) should be counseled regarding the risk of transmission from cats.

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