Download Bartonella henselae infection in a man with

Journal of Medical Microbiology (2013), 62, 338–341
Case Report
DOI 10.1099/jmm.0.052134-0
Bartonella henselae infection in a man with
hypergammaglobulinaemia, splenomegaly and
polyclonal plasmacytosis
Nandhakumar Balakrishnan,1 Jaspaul S. Jawanda,2 Melissa B. Miller3
and Edward B. Breitschwerdt1
Correspondence
Edward B. Breitschwerdt
[email protected]
1
Intracellular Pathogens Research Laboratory, Center for Comparative Medicine and Translational
Research, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
2
First Health Infectious Diseases, Moore Regional Hospital, 155 Memorial Drive, PO Box 3000,
Pinehurst, NC, USA
3
Clinical Molecular Microbiology Laboratory, University of North Carolina School of Medicine,
Chapel Hill, NC, USA
Received 10 September 2012
Accepted 25 October 2012
Bartonella henselae is an infrequently reported cause of polyclonal plasmacytosis and
hypergammaglobulinaemia. We herein document B. henselae infection in a 66-year-old patient
who presented with hypergammaglobulinaemia, splenomegaly with polyclonal plasmacytosis,
stroke, and suspected prosthetic aortic arch infection. Clinicians should remain cognizant of the
heterogeneous clinical presentations associated with bartonellosis.
Introduction
Bartonella species are fastidious Gram-negative, arthropod-transmitted bacteria that are capable of causing
long-lasting intraerythrocytic bacteraemia in mammals.
Frequently reported disease manifestations include nonspecific malaise, adenitis, endocarditis and vasoproliferative lesions. As confirmation of Bartonella species infection
by culture is the exception rather than the rule, serology,
pathology and PCR amplification of organism-specific
DNA sequences can facilitate diagnosis (Versalovic et al.,
2011). The combination of hypergammaglobulinaemia,
splenomegaly and polyclonal plasmacytosis is not known
to have been reported in a human patient infected with a
Bartonella species. Herein, we report a patient infected with
Bartonella henselae that experienced hypergammaglobulinaemia, splenomegaly with polyclonal plasmacytosis,
stroke and suspected infection of an aortic arch graft.
Case report
A retired 66-year-old male crop farmer had a history of atrial
fibrillation, and placement of a coronary artery bypass graft,
Dacron aortic arch graft and bioprosthetic aortic valve. He
resided in a semi-rural area of North Carolina and had
contact with outdoor cats. In July 2010, he reported
persistent malaise, fatigue, low-grade fever and myalgia.
Erythrocyte sedimentation rate was 84 mm h21; differential
blood cell counts and a transthoracic echocardiogram were
Abbreviations: anti-SSA, anti-Sjögren’s syndrome A; PET, positron
emission tomography; POD, post operative day(s).
338
normal. A complete haemogram was unremarkable.
Automated blood cultures (six sets obtained on three
occasions) were negative. In September 2010, a temporal
artery biopsy and rheumatologic evaluation were unrevealing, yielding a potential diagnosis of polymyalgia rheumatica. Antinuclear antibody by immunofluorescent antibody
testing was negative, anti-Sjögren’s syndrome A (anti-SSA)
antibodies were positive at a level of .8.0 antibody index
units, with no clinical evidence of Sjogren’s syndrome. A
magnetic resonance imaging (MRI) scan defined only agerelated atrophy. Prednisone therapy was begun at 60 mg
daily and then tapered to 10 mg daily after 2 months,
eliciting transient improvement. However, there was then an
indolent decline in functional status. In February 2011, the
patient reported confusion and worsening cognition. He was
thromobocytopenic (138 000 ml), hyperproteinemic (9.0 g
dl21) and hypergammaglobulinaemic (IgG 5065 mg dl21;
reference range 700–1600), with a polyclonal gammopathy.
The spleen was palpable and abdominal computerized
tomography (CT) identified marked, homogeneous splenic
enlargement (Fig. 1a). Cytopathology of a bone marrow
specimen revealed mild hypercellularity with polytypic
plasmacytosis (10 %), and no immunophenotypic or
cytogenetic abnormalities. In April 2011, a positron
emission tomography (PET) scan identified increased
metabolic activity in the spleen and ascending aorta (Fig.
1b, c). As lymphoma was suspected, splenectomy was
performed. Grossly the spleen contained small infarcts.
Histopathology revealed prominent polyclonal plasmocytosis with normal B cell immunophenotype (Fig. 1d). During
post operative days (POD) 5–17, the patient developed a
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Bartonella and splenic plasmacytosis
(a)
(c)
(b)
(d)
right middle cerebral artery infarct, subsequently with left
basal ganglia and focal occipital haemorrhage. During the
post operative course, he developed intermittent fever and
confusion. Automated blood cultures were again negative
and no vegetations were observed by transoesophageal
echocardiogram. Due to suspected prosthetic aortic arch
graft infection, fastidious bacteria that have been
associated with culture-negative endocarditis became a
diagnostic consideration. The patient’s B. henselae and
Bartonella quintana IgG titres (ARUP Laboratories) were
1 : 2048 and 1 : 128, respectively. On POD 28, stored
formalin-fixed and paraffin-embedded splenic tissues
were submitted to the Intracellular Pathogens Research
Laboratory, North Carolina State University, for Bartonella species PCR. Previously, we described Bartonella
spp. DNA carryover during animal necropsy, and during
the subsequent processing of tissue samples (Varanat et al.,
2009a). Hence, special precautions are routinely taken in
our laboratory when sampling paraffin blocks to minimize
the DNA cross-contamination. Using a sterile scalpel,
multiple sections were sliced from formalin-fixed and
from paraffin-embedded splenic tissues, after which DNA
was extracted using a Qiagen DNeasy Blood and Tissue kit
according to the manufacturer’s instructions. For each
PCR, a negative control was processed to ensure that
extraction buffers and reagents were not contaminated
with Bartonella DNA. PCR amplification using broadrange 16S rDNA gene primers yielded negative results
(Arosio et al., 2008). PCR targeting the 16S–23S rRNA
intergenic spacer (ITS) region of the Bartonella genome
was performed as previously described (Maggi et al.,
http://jmm.sgmjournals.org
Fig. 1. Abdominal CT identified marked,
homogeneous splenic enlargement (a). A PET
scan identified increased metabolic activity
in the anterior mediastinum/anterior wall of
the ascending aorta (b) and spleen (c).
Histopathology revealed prominent polyclonal
plasmocytosis with normal B cell immunophenotype (d).
2005). No amplicons were obtained from the splenic
tissue maintained for 28 days in formalin, whereas B.
henselae DNA was amplified and successfully sequenced
from three of five paraffin-embedded splenic tissue
sections (Fig. 2). Presumably, long-term fixation in
formalin resulted in cross-linking and fragmentation of
DNA, thereby interfering with PCR amplification as
compared with the short duration of fixation prior to
embedding of the splenic tissue in paraffin.
Beginning on POD 27, the patient was treated with
doxycycline and gentamicin for 2 weeks, followed by
doxycycline and rifampicin for several weeks. Due to an
adverse rifampicin–warfarin interaction, rifampicin was
discontinued and doxycycline monotherapy was continued
for 5 months. Beginning on POD 157, oral azithromycin
250 mg once daily for 10 months was administered.
Revision cardiac surgery was not pursued, taking into
account the patient’s frailty and his wishes. Upon receiving
antibiotics, he dramatically improved. At 8 months postdiagnosis, the B. henselae IgG titre had decreased to 1 : 128.
The patient had improved remarkably, and oral azithromycin was continued. Despite administration of antibiotics
for 1 year, mild headaches persisted. By June 2012, a repeat
MRI was unremarkable; however, his B. henselae antibody
titre had increased to 1 : 2048.
Discussion
Prior to splenectomy, this patient experienced a protracted
illness and complex disease course that defied a definitive
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339
N. Balakrishnan and others
1
2
3
4
5
6
7
8
9
10
11
Fig. 2. PCR of Bartonella genus and specific 16–23S internal
transcribed spacer (ITS) elements on paraffin-embedded and
formalin-fixed splenic tissue. Lanes: 1, 6 and 11, 1 kb molecular
mass marker; 2, formalin-fixed tissue tested for Bartonella spp.; 3,
paraffin-embedded tissue tested for Bartonella spp.; 4, positive
control (B. henselae, 0.01 pg ml”1); 5, negative control; 7,
formalin-fixed tissue tested for Bartonella koehlerae; 8, paraffinembedded tissue tested for B. koehlerae; 9, positive control (B.
koehlerae, 0.01 pg ml”1); 10, negative control.
diagnosis. The development of a post-operative fever, in
conjunction with the presence of prosthetic implants and
numerous negative pre- and post-operative blood cultures,
facilitated diagnostic consideration of culture-negative
endocarditis (Fournier et al., 2010). Subsequent serological
and molecular testing confirmed B. henselae infection.
Although fever often accompanies an acute infection with
B. henselae, immunocompetent patients with chronic
bacteraemia are rarely febrile. Fever was only documented
in this patient in July 2010, and post-operatively in April
2011. Although they are very non-specific symptoms,
malaise, fatigue, myalgia and neurocognitive abnormalities
are often reported in patients with chronic Bartonella
bacteraemia (Breitschwerdt et al., 2007, 2011).
The clinical association between polyclonal gammopathy
and chronic infection with intracellular bacteria or
protozoa is well established; however, determining the
infectious cause of hypergammaglobulinaemia can be
challenging in some patients. Although infrequently
reported to date, monoclonal and biclonal gammopathies
have been reported in association with B. henselae
infections (Krause et al., 2003). However, plasmacytosis
in the bone marrow and the spleen, as documented in this
patient, are not known to have been described before in
association with B. henselae infection. Based upon repeated
interpretations by veterinary pathologists, hypergammaglobulinaemia and plasma cell infiltration of bone
spanning an 18-month time frame have been reported in
a cat with multifocal osteomyelitis in association with
Bartonella vinsonii subspecies berkhoffii bacteraemia
340
(Varanat et al., 2009b). Thus, infection with a Bartonella
species should be included in the differential diagnostic
consideration for patients with unexplained plasma cell
infiltration, splenomegaly, hypergammaglobulinaemia and
polyclonal or monoclonal gammopathy. The spleen is
occasionally involved in Bartonella species infections.
Typically, hypodense lesions are reported on radiographic
imaging. When these areas are biopsied, one most
commonly encounters necrotizing granulomas. In our
patient, despite the lack of granulomatous inflammation,
serology, PCR amplification and DNA sequencing results
supported infection with B. henselae as a unifying
diagnosis. In addition, splenic Bartonella infection has
been reported in a patient following splenectomy performed for suspected malignancy (Ghez et al., 2001).
Based upon this patient’s symptoms and rheumatological
testing, including a positive anti-SSA, prednisone was
administered for several months prior to surgical intervention. The PET scan demonstrated increased metabolic
activity in the ascending aorta, which in retrospect,
potentially supported localization of B. henselae organisms
to this anatomical location. Previous studies have identified pre-existing valvular disease as a risk factor for the
development of B. henselae endocarditis (Fournier et al.,
2010). In two earlier case reports, patients developed
endocarditis after therapeutic immunosuppression was
initiated based upon positive anti-neutrophil antibody
tests (Turner et al., 2005). Similarly, B. vinsonii subspecies
berkhoffii genotype I endocarditis was reported in a dog
from North Carolina after therapeutic immunosuppresion
was initiated for suspected systemic lupus erythematosus,
based upon positive anti-nuclear antibody reactivity
(Breitschwerdt et al., 1995). Thus, it is possible that
immunosuppression may facilitate B. henselae localization
to heart valves or to prosthetic implants, and based upon
the patient’s most recent B. henselae titre, antibiotic
elimination of these bacteria may be difficult to achieve.
Based upon multiple patient management factors, cardiac
revision surgery was not performed to address a potentially
infected bioprosthetic aortic valve or Dacron aortic arch
implant.
Based upon recent research observations, infections
with Bartonella species represent a previously unrecognized cause of persistent bacteraemia in immunocompetent patients. Infection with a spectrum of Bartonella
species is an important diagnostic consideration in
patients with culture-negative endocarditis and is also
occasionally encountered in patients with prosthetic
valve endocarditis.
Conclusion
Based upon this case report, bartonellosis should be
considered in patients with unexplained fatigue, myalgia,
neurocognitive abnormalities, splenomegaly, hypergammaglobulinaemia and splenic or bone marrow plasmacytosis. Clinicians should consider bartonellosis as a
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Journal of Medical Microbiology 62
Bartonella and splenic plasmacytosis
differential diagnosis in an expanding number of clinical
scenarios.
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Ghez, D., Bernard, L., Bayou, E., Bani-Sadr, F., Vallée, C. & Perronne,
C. (2001). Bartonella henselae infection mimicking a splenic
lymphoma. Scand J Infect Dis 33, 935–936.
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