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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>Organ System>
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Bacillary angiomatosis

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

  • 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

PATHOGENS

  • 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.

CLINICAL

  • 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.

DIAGNOSIS

  • 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.

TREATMENT

Immunocompromised hosts

Drug Comments

DrugRecommendations/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 UP

  • 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.

OTHER INFORMATION

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

Pathogen Specific Therapy

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