Human Bartonellosis caused by Bartonella bacilliformis

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Human Bartonellosis caused byBartonella
bacilliformis
2
César Henríquez1 Paul Pachas2 Phillip
Lawyer3 Larry Laughlin3 Ciro Maguiña1
1. Instituto de Medicina Tropical Alexander von
Humboldt-Universidad Peruana Cayetano Heredia 2.
Oficina General de Epidemiologia 3. Uniformed
Services University of the Health Sciences
2002
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Introduction

• Human bartonellosis is the clinical term to
  define the bacterial infections by the genus
  Bartonella.
• There are five important species that produce
  human diseases.

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History and Archeology
Bartonellosis has been known since Pre-Inca
times. Numerous artistic representations in clay
huacos depict the chronic phase of the disease.
For a long time it was thought that the disease
was endemic only in Peru and that it had only one
phase Peruvian wart or Verruga peruana
The historian Garcilazo De La Vega described a
disease with warts in Spanish troops when they
arrived for the first time in Coaque-Ecuador.
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Historical Figures
In 1875 an outbreak, characterized by fever and
anemia (Oroya fever) occurred in the region of
construction of the railroad line between Lima
and Oroya. In 1885, Daniel A. Carrion, a
Peruvian medical student, inoculated himself with
material taken from a patient with Peruvian wart.
He subsequently acquired Oroya fever and died a
month later. Later, Alberto Barton discovered
the etiologic agent of Carrions disease
Dr. Alberto L. Barton (1871-1950)
Daniel A. Carrión (1858-1885)
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Epidemiology

• Bartonellosis is endemic in Perú, Ecuador and
  Colombia.
• Geography and weather conditions vary depending
  of the region.
• Emergence or re-emergence of several infectious
  diseases, including bartonellosis, seem to
  coincide with el Niño weather phenomena.

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Carrions disease cases (1945-2001)
YEAR
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Ancash department was the most important endemic
area of bartonellosis since 1945 until 1994.
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Reported cases of Carrions disease (1995-2001)
1997
1999
1995
2001
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Incidence of Carrions disease by regions
(1996-2002)
YEARS
Coast Jungle
Andes
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New foci of Carrions disease
New epidemic areas identified. Mortality during
the outbreaks is high. No cases of chronic
phase (Peruvian wart)in epidemic areas. No
animal reservoir identified.
February 2002
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Suspected vectors Phlebotomine sand flies

• Smaller than a mosquito, larger than a midge
• Coloration varies from light brown (sandy or
  fawn) to gray or black
• Require humid, not wet, conditions
• Only female sand flies take a blood meal
• Nocturnal feeding behavior

Lutzomyia verrucarum Photo Courtesy Dr.Grieco and
Dr. Lawyer
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Suspected Vectors Phlebotomine sand flies

• Sand fies are weak fliers
• Fly only at night unless disturbed in their
  daytime resting site
• Sand flies transmit Bartonella bacilliformis from
  infected to uninfected hosts by bite
• At least two species suspected in Peru Lu.
  verrucarum and Lu. peruensis

Lutzomyia peruensis Courtesy Dr.Grieco and Dr.
Lawyer
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Distribution of Carrions disease cases and
Lutzomyia verrucarum

• Provinces with
• Lutzomya verrucarum

Provinces with Carrions disease cases
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Etiologic agent Bartonella bacilliformis
Gram negative aerobic, pleomorphic, flagellated,
motile, coccobacillary, 2-3 ?m large and 0,2 -
0,5 ?m wide and facultative intracellular
bacterium. For its isolation, special cultures
are required containing complemental soy agar,
proteases, peptones, some essential amino acids
and blood. The optimum growing temperature is
19-29 ºC.
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Pathogenesis

• Bartonella bacilliformis is transmitted by the
  bite of the suspected vector Lutzomyia spp
• Following transmission, the bacterium infects red
  blood cells and endothelial cells
• The physical damage and introduction of antigens
  in the membranes of the red cells stimulate the
  Reticuloendothelial System to produce an intense
  erythrophagocytosis by macrophages and
  histiocytic cells resulting in severe extra
  vascular hemolytic anemia

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Endothelial cells the last target?

• The invasion of endothelial cells is an active
  process dependent on the activation of Rho, which
  is an intracellular signal implicated in the
  rearrangement of the host cell actin cytoskeletal
  network

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The disease

• The clinical symptoms of bartonellosis are
  pleomorphic and some patients may be asymptomatic
  
• The two classical clinical presentations are the
  acute phase and the chronic phase, corresponding
  to the two different host cell types invaded by
  the bacterium

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Acute phase Oroya fever or Carrions disease

• The mean incubation time is 21 days (range 10 to
  270 days)
• The diagnostic tests in this phase are

Values in porcentaje
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The diagnosis
The diagnosis in the acute phase can be done
using the thin blood film with Giemsa stain. It
is possible to observe the bacillus inside the
red blood cells.
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Molecular technics
M DNA ladder (100 bp). 1 B. bacilliformis DNA
from culture extracted by thermal lysis (100C,
10 min.) using 16S 23S primers (positive
control). 2 Whole blood extraction from an acute
phase patient, using 16S 23S primers. 3 Whole
blood extraction from an acute phase patient,
using primers for Citrate Synthetase gene. 4 B.
bacilliformis DNA from a culture extraction using
primers for Citrate Synthetase gene.
M 1 2 3 4
Base pairs
1500 bp
600 bp
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Immunologic technics Sonicated immunoblot
Lane A Positive control pool Lane Band C
Bartonella bacilliformis-positive serum taken
from a patient in acute phase Lane D Negative
control pool
20 kDa
18 kDa
17 kDa
14 kDa
A B C D
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Chronic Phase Peruvian wart (Verruga Peruana)
Mularlesions
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Chronic Phase Peruvian wart (Verruga Peruana)
Miliary lesions
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Chronic Phase Peruvian wart (Verruga Peruana)
Miliary lesions with overwhelming infection
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Chronic phase some numbers

• The diagnostic tests in this phase are blood
  culture (13 of patients with verruga have
  bacteriemia), culture of the verrugous warts and
  Immunoblot with a sensitivity of 70 and
  specificity of 100
• The IFA has a sensitivity of 82 and specificity
  of 92

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Immunity and infection

• One factor that complicates the clearance of the
  bacterium is that intra-erythrocytic Bartonella
  are protected from both humoral and cellular
  immune responses due to a lack of major
  histocompatibility complex (MHC) molecules on the
  surface of the mature erythrocytes
• They are unable to present antigens of their
  invaders to the immune system

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Conclusion

• Human bartonellosis is a bacterial infection by
  the genus bartonella
• Bartonellosis caused by B. bacilliformis (Oroyas
  fever or Carrions disease) is endemic in Peru,
  Ecuador and Colombia
• No animal reservoir identified
• Suspected vectors Phlebotomine sand flies
• About the disease, there are two classical
  clinical presentations acute and chronic phase
• New endemic areas identified Emergent infectious
  disease