Bartonella

Prepared by:
Ohood R. Sarsour
 Introduction
 Bartonella species (formerly known as
Rochalimaea)
 Linked to a number of emerging zoonotic diseases
 B.quintana, B.bacilliformis, B.henselae
 Unique and common feature is ability to cause
vasoproliferative lesions (process of pathological
angiogenesis)
 Infection affects function of endothelial cells
resulting in cell invasion, suppression of apoptosis
and induction of proliferation, resulting in
vasoproliferative tumor growth
 B. henselae
 Gram negative aerobic rods
 Main reservoir is cats
 Transferred to humans through scratches and bites
(fleas/ticks??)
 Resulting illness is Cat Scratch Disease (CSD)
 About 40% of cats carry B.henselae
 Cats are asymptomatic, although bacteria can be
cultivated from their blood for up to 2 years
 This persistent infection due to persistence in red blood
cells
 Epidemiology
 Cases of CSD occur worldwide
 Higher incidence of Bartenellosis in warmer
and more humid areas of the United States
 More fleas and ticks
 Children 2-24 and veterinarians make up
80-90% of human cases
 22 000 cases of CSD are diagnosed per year
in the United States
 Most cases occur in late fall and winter
 Infections
 CSD is a self-limiting disease characterized by
lymphadenopathy and infection at the site of injury
 Lasts 6-12 weeks in healthy individuals and can be
accompanied by headaches, nausea, vomiting and
fatigue
 Severity of CSD depends on immune status of the
host
 Immunocompromised individuals can develop
Bacillary angiomatosis (BA) and Parinaud’s
oculoglandular syndrome (POS)
 Diagnosis is difficult and is usually based on
exposure to a cat, enlarged lymph nodes and
lack of another appropriate cause
 Virulence Factors
 VEGF (vascular endothelial growth factor)
 Triggers angiomatosis and has a pathogenic role
in vasoproliferative disorders (such as BA)
 Highly mitogenic to endothelial cells

 B.henselae induces host cell production of VEGF

 This production and subsequent proliferation is

necessary for angiogenesis and BA
 This proliferation also promotes growth of
B.henselae’s own cells
 Pili
 Expression of pili allows adhesion and invasion of
host cells
 Pili are also thought to be responsible for the
induction of VEGF as pili- mutants have a
significant decrease in production of VEGF
 Type 4 secretion system (virB-D4)
 Consists of a multiprotein channel that allows
transportation of DNA or protein into the host
cell
 virB operon encodes 10 genes, 8 of which known
to encode a T4SS
 virD4 locus located just downstream

 virB5 encodes a 17kD protein found in patients

with CSD
 Function not known but not found outside
Bartonella species
 Downstream region of virB encodes Bep proteins
that are translocated into the endothelial cells
 These proteins thought to mediate all virB-virD4-
dependent changes of endothelial cell function
 Recent studies have shown that a mutation in
either virB or virD4 prevents intraerythrocytic
infection as well as endothelial cell invasion
 Type 4 Secretion System (Trw)
 Second T4SS identified that is active during
endothelial cell infection
 Primary function to establish contact with
erythrocytes through surface expressed T4SS pili
 Deformin
 Hydrophobic secreted protein
 Affinity for albumin

 Formation of pits and trenches on red blood cell

membranes that aids in colonization and entry
to the cell
 Outer Membrane Proteins (OMPs)
 Induce NFκB-dependent upregulation of E-
selectin and ICAM-1
 Leads to increased adhesion molecule expression

 NFκB plays a role in initiation and regulation of

the body’s proinflammatory response
 Persistent Infection
 Endothelial cell interaction
 Primary niche
 Most information gathered using HUVEC cells

 Bartonella species can enter endothelial cells by

rearranging actin cytoskeleton
 B.henselae can also enter using “invasome”
mechanism
 Bacterial aggregate formation on cell surface that is
engulfed and internalized through an actin-
dependent process
 Intraerythrocytic persistence
 Common theme of Bartonella is prolonged
intraerythrocytic bacteremia associated with
transmission by blood-sucking arthropods
 Adherence mediated by pili and OMPs exposed
on bacterial surface
 Exact mechanism is not known but assumed to
be bacterial-induced endocytosis
 Assisted by deformin secretion
 After invasion intracellular multiplication occurs
 Limited by quorum sensing to prevent hemolysis

 Bacteria survive for the duration of the cell life and

remain in the blood stream for several weeks, facilitating
transmission
 Bacteria seeded into blood stream every 5 days
 Unique persistence is an adaptation to mode of
transmission
 Intraerythrocytic bacteremia subsides due to strong IgG
antibody response (in animal models)
 Prevention and Treatment
 Proper cat care
 Keeping cats indoors
 Using flea products

 Prevent roughhousing with kittens

 Do not let cats like open wounds

 Wash cat wounds out with warm water

 Most healthy people recover without
treatment in anywhere from 3 weeks to
several months
 Immunocompromised individuals may
develop more serious complications and
possibly death
 If antibiotics are prescribed
 Erythromycin, rifampin, doxycycline
 Antibiotics can not reach intraerythrocytic
bacteria but can prevent new waves of
parasitism
 A recent study has shown that cats treated
for bacteremia caused by B.henselae were
resistant to reinfection when challenged
following recovery
 B.quintana
 Facultative,intracellular,gram negative rod.
 Catalase and oxidase reactions are negative.
 The bacterium can be grown on axenic media
 When grown on blood agar,rough colonies
embedded in the agar obtained after 12to14 days
 Humans are the reservoir of the bacterium,and
the human body louse is its usual vector
 The bacterium has atropism for endothelial
cells,leading to angioproliferative
lesions,observed in bacillary angiomatosis.
 Transmission
 B.quintana is
transmitted by the
human body louse,
which lives in clothes
 Clinical Manifestations
 Trench Fever.
 Chronic Bacteremia.

 Endocarditis.

 Bacillary Angiomatosis.

 Lymphadenopathy.
 Diagnosis
 Serologic tests

Western blot and cross-adsorption results in a patient

with Bartonella quintana endocarditis. A) Nonadsorbed. B)
Adsorbed with B. quintana. C) Adsorbed with B. henselae. Lane 1,
B. quintana; lane 2, B. henselae; lane 3, B. elizabethae; lane 4, B.
vinsonii subsp. Berkhoffi; lane 5, B. vinsonii subsp. Arupensis.
Before adsorption (A), antibodies are detected against all species
(1, 2, 3, 4, and 5). After adsorption with B. quintana antigen (B), all
antibodies disappear. After adsorption with B. henselae antigen
(C), antibodies against B. quintana (1) persist. This reaction shows
B. quintana infection.
  Culture.
 Molecular Biology.
 Immunohistochmistry
and Immunoflurescence.

. Immunohistochemical demonstration of Laser confocal microscopy showing the intraerythrocytic

Bartonella sp location of Bartonella quintana.
Antimicrobial drug susceptibility of
B. quintana
 Evaluation of susceptibilities to antimicrobial
drugs has been performed in both axenic media
and cell culture.
 Penicillines,cephalosporins,aminoglycosides,chlo
ramphenicol,tetracyclines,rifampin,fluoroquinolo
nes,and cortimonazole.
 However only aminoglycosides have
bactericidal effect.
 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.
 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
Lutzomyia
take a blood meal verrucarum
• Nocturnal feeding
behavior
 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 Lutzomyia
suspected in Peru: Lu. peruensis
verrucarum and Lu.
peruensis
 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
 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
 Acute phase: Oroya fever or
Carrion’s disease
 The mean incubation time is 21 days
(range 10 to 270 days)
 The diagnostic tests in this phase are:

Diagnostic test Sensitivity Specificity

Blood smear 36-73 91-96
Immunoblot 70 94
PCR(16S-23S) 47 98

Values in porcentaje
 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.
 Immunologic technics:
Sonicated immunoblot
Lane A: Positive control
pool
20 kDa
18 kDa Lane Band C:
17 kDa
14 kDa Bartonella bacilliformis-
positive serum taken
from a patient in acute
phase
Lane D: Negative
A B C D control pool
 Molecular technics
M: DNA ladder (100 bp).
M 1 2 3 4 1: B. bacilliformis DNA from
culture extracted by thermal lysis
Base
pairs
(100°C, 10 min.) using 16S 23S
primers (positive control).
2: Whole blood extraction from an
acute phase patient, using 16S
23S primers.
1500 bp
3: Whole blood extraction from an
600 bp acute phase patient, using primers
for Citrate Synthetase gene.
4: B. bacilliformis DNA from a
culture extraction using primers
for Citrate Synthetase gene.
Chronic Phase: Peruvian wart
(Verruga Peruana)

Mularlesions
Chronic Phase: Peruvian wart
(Verruga Peruana)

Miliary lesions
Chronic Phase: Peruvian wart
(Verruga Peruana)

Miliary lesions with overwhelming infection

 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%
 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