Bartonellosis - Peru (Lima State)

International Society for Infectious Diseases
<http://www.isid.org>

Source: RPP Noticias, Peru, [translation by JG; edited]
< http://www.rpp.com.pe/portada/nacional/50004_1.php>


One person died because of bartonellosis or Carrion's disease in
Santa Eulalia, Peru, 50 km east of Lima in an area with many country
restaurants visited each weekend by thousands of  people.
Bartonellosis is an endemic infection in the Andean region,
characterized by progressively worsening hemolytic anemia and febrile
illness, which is transmitted by _Lutzomyia_  sand flies and is
caused by the bacterium _Bartonella bacilliformis_.

Dr. Ciro Maguina, one of the most important infectious diseases
experts in Peru, who was awarded the Roussel Prize in 1993 because of
research he carried out on bartonellosis, pointed out thousands of
people visit every day Andean areas, such as Ancash, Cajamarca, or
Cusco, and they are bitten by sand flies, but very few develop
symptoms. "Reported cases are timely treated and easily cured,"
assured Dr. Maguina.

In 2005, there were more than 11 000 cases of bartonellosis reported
and treated in Peru, and in 2006 reports indicate 3000 cases.

In a related report, a new case of bartonellosis was reported in a
17-year-old woman hospitalized in Cayetano Heredia Hospital
(affiliated with Cayetano Heredia Medical School) in Lima. The woman
had been suffering from fever for 30 days; like the case reported
above, she may also have acquired the disease in Santa Eulalia.

Bartonellosis has 2 forms of presentation. First, the cutaneous form
(verruga or warts), which most frequently affects persons from
endemic areas, and the hemolytic /febrile form, which most frequently
affects people traveling to endemic areas. It should be pointed out
that _B. bacilliformis_ is quite susceptible to most antibacterial
agents. Diagnosis can be made on the basis of travel/exposure history
and with a single thin blood smear in which the microorganism can be
seen associated with red blood cells. Bartonellosis must always be
included in the differential diagnosis list for febrile illness in
certain areas of Peru.

Bartonellosis comprises infections caused by newly emerging
pathogens. In 1909, AL Barton described organisms that adhered to red
blood cells (RBCs). The name _Bartonia_, later _Bartonella
bacilliformis_, was used for the only member of the group identified
before 1993. _Rochalimaea_ (named for Rocha-Lima), a similar group,
were recently combined with Bartonella. Although these organisms were
originally thought to be rickettsiae, Bartonella bacteria can be
grown on artificial media, unlike rickettsiae.

At least a dozen species belong to the genus _Bartonella_. Three
species are considered important causes of human disease, but other
significant human pathogens in this genus will undoubtedly be found
in the future. _B. bacilliformis_ causes Oroya fever and verruga
peruana. _Bartonella henselae_ causes cat scratch disease (CSD).
_Bartonella quintana_ causes trench fever. Either _B. henselae_ or
_B. quintana_ may cause peliosis of the liver (often called bacillary
peliosis; characterized by cystic, blood-filled spaces in the liver),
infections in homeless populations, and infections in patients with
human immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS). New species that may cause human disease include
_Bartonella vinsonii_, _Bartonella clarridgeiae_, and _Bartonella
elizabethae_. Several of these other species are found in animals.

Portions of the following were extracted from
< http://www.healthatoz.com/healthatoz/Atoz/ency/bartonellosis.jsp>:

The acute form of the disease caused by _B. bacilliformis_ gets its
name from an outbreak that occurred in 1871 near La Oroya, Peru. More
than 7000 people perished. Some survivors later developed a skin
disease called verruga peruana (Peruvian warts). These skin lesions
were observed prior to the 1871 outbreak -- perhaps as far back as
the pre-Columbian era -- but a connection to Oroya fever was unknown.
In 1885, a young medical researcher, Daniel Carrion, inoculated
himself with blood from a lesion to study the course of the skin
disease. When he became ill with Oroya fever, the connection became
apparent. Oroya fever is often called Carrion's disease in honor of
his fatal experiment.

Although the bacterium, _Bartonella bacilliformis_, was isolated by
Alberto Barton in 1909, it was not identified as the cause of the
fever until 1940. The Bartonella genus includes at least 11 bacteria
species, 4 of which cause human diseases, including cat-scratch
disease and bacillary angiomatosis. However, bartonellosis generally
refers exclusively to the disease caused by _B. bacilliformis_. The
disease is limited to a small area of the Andes Mountains in western
South America; nearly all cases have been in Peru, Colombia, and
Ecuador. A large outbreak involving thousands of people occurred in
1940-41, but bartonellosis has since occurred sporadically. Control
of sandflies, the only known disease vector, has been credited with
managing the disease.

Once in the bloodstream, the bacteria attach to red blood cells
(erythrocytes).  For a picture of a blood smear with the organism
associated with red blood cells see:
< http://web.umr.edu/~microbio/BIO221_2004/bartonella-1.jpg>.

In the process, up to 90 percent of the host's erythrocytes are
destroyed, causing severe hemolytic anemia. The anemia is accompanied
by high fever, muscle and joint pain, delirium, and sometimes coma.

An infected individual develops verruga peruana 2-8 weeks after the
acute phase. However, individuals may exhibit the characteristic
lesions without ever experiencing the acute phase. Left untreated,
the lesions may last months or years. These lesions resemble
blood-filled blisters, up to 4 cm in diameter, and appear primarily
on the head and limbs. They can be painful to the touch and may bleed
or ulcerate; see:
< http://pathmicro.med.sc.edu/mayer/Bartonellosis8.jpg>.

Bartonellosis is identified by symptoms and the patient's history,
such as recent travel in areas where bartonellosis occurs. Isolation
of _B. bacilliformis_ from the bloodstream or lesions can confirm the
diagnosis. Antimicrobial agents are the mainstay of bartonellosis
treatment. The bacteria are susceptible to several antibiotics,
including chloramphenicol, penicillins, and aminoglycosides. Blood
transfusions may be necessary to treat the anemia caused by
bartonellosis.

Antibiotics have dramatically decreased the fatality associated with
bartonellosis. Prior to the development of antibiotics, the fever was
fatal in 40 percent of cases. With antibiotic treatment, that rate
has dropped to 8 percent. Fatalities can result from complications
associated with severe anemia and secondary infections. Once the
infection is halted, an individual can recover fully.