Bacillary angiomatosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Bacillary angiomatosis (BA) is a bacterial infection caused by either Bartonella henselae or Bartonella quintana. Bartonella henselae is most often transmitted through a cat scratch or bite, though ticks and fleas may also act as a vector. On the other hand, Bartonella quintana is usually transmitted by lice.

Pathophysiology

Bacillary angiomatosis is characterized by the proliferation of blood vessels, resulting in them forming tumor-like masses in the skin and other organs. It most commonly manifests in people with AIDS, rarely appearing in those who are immunocompetent. While curable, it is potentially fatal if not treated.

Differential Diagnosis

Bacillary angiomatosis should be differentiated from other diseases presenting as purplish papules or nodules on extremities. The differentials include the following:

Diseases	Etiology	Congenital	Acquired	Demography	Clinical manifestations							Lab findings						Gold standard diagnosis	Associated findings
					Symptoms			Signs				CBC			LFT	ESR/CRP	Histopathology
					Appearance	Fever	Bleeding	BP	Hepatosplenomegaly	Lymphadenopathy	Other	WBC	Hb	Plt
Bacillary angiomatosis	HIV Chronic lymphocytic leukemia Cytotoxic chemotherapy Organ transplantation	–	+	Any age, usually between 20 -50 years	Solitary or multiple red, purple, flesh-colored, or colorless papules	±	±	Nl	–	–	Anorexia Weight loss Abdominal pain Nausea and vomiting Headache	Nl	Nl	Nl	Nl	Nl	Lobular vascular proliferations of vessels lined by plump endothelial cells	Clinical manifestation	Psychiatric disorders Personality changes Seizure
Arteriovenous malformation	Idiopathic	+	–	Any age	Nl	–	+	Nl	–	–	Headache Neurologic deficits Heart failure Macrocephaly	Nl	Nl	Nl	Nl	Nl	NA	Imaging	Hereditary hemorrhagic telangiectasia
Acroangiodermatitis	Idiopathic Hyperplasia of pre-existing vasculature HTN	–	–	Any age, more in males	Purplish-blue to brown papules and plaques	–	–	Nl	–	–	Paralysed legs	Nl	Nl	Nl	Nl	Nl	Hyperkeratosis Parakeratosis Acanthosis Mild spongiosis	Clinical manifesttations	Amputation Haemodialysis patients with arteriovenous shunts Hepatitis C Chronic venous insufficiency AV malformations
Angiosarcoma	Idiopathic	–	–	Adults, more in males	Enlarging bruise, a blue-black nodule, or an unhealed ulceration	–	–	Nl	–	–	–	Nl	↓	↓	Nl	Nl	Intercellular and intracellular lumina with or without red cells Intermediate filaments and pinocytotic vesicles in cytoplasm Weibel-Palade bodies	Biopsy	NA
Diseases	Etiology	Congenital	Acquired	Demography	Appearance	Fever	Bleeding	BP	Hepatosplenomegaly	Lymphadenopathy	Other	WBC	Hb	Plt	LFT	ESR/CRP	Histopathology	Gold standard diagnosis	Associated findings
Masson's hemangioma	Idiopathic	–	–	Rare	Normal	–	–	Nl	–	–	–	Nl	Nl	Nl	Nl	Nl	Papillary fronds lined by proliferating endothelium	Biopsy	Hemangioma Pyogenic granulomas Lymphangiomas
Seborrheic keratosis	Clonal expansion of a mutated epidermal keratinocyte	+	–	Any age	Usually asymptomatic Being stuck on the skin surface	–	–	Nl	–	–	–	Nl	Nl	Nl	Nl	Nl	Papillomatous epithelial proliferation containing horn cysts	Clinical manifestations	Dermatosis papulosa nigra Stucco keratosis Melanoacanthoma Polypoid lesions
Systemic lupus erythematosus (SLE)	Idiopathic	–	–	More common in female, typically in the 20 to 30 years	Erythema on the nasolabial folds Macular or diffusely erythematous in sun-exposed areas Discoid rash	±	–	↑	±	±	Weight loss Headache Arthralgia Myalgia Nausea Dyspepsia Pleuritic chest pain Dyspnea Hematuria	↑	↓	↓	Nl	Nl	Hyperkeratosis, epidermal atrophy, vacuolar interface dermatitis Thickening of the basement membrane Superficial, perivascular, and perifollicular mononuclear cell inflammatory infiltrate	Clinical manifestations	Raynaud phenomenon Neuropsychiatric symptoms Pleural effusion Peptic ulcer disease Pericarditis Myocarditis
Pyogenic granuloma	Trauma Hormonal influences Viruses Cytogenetic clonal deletion abnormalities	+	+	Any age, usually in 20-30 years	Painless red lesion Lobular capillary hemangioma	–	+	Nl	–	–	–	Nl	Nl	Nl	Nl	Nl	Neutrophilic infiltration Hemorrhage Necrosis of the overlying epidermis	Clinical manifestation	NA
Benign lymphangioendothelioma	Idiopathic	–	+	Any ages, median age is 50 years	single, slowly expanding patch, plaque, or nodule	–	–	Nl	–	–	–	Nl	Nl	Nl	Nl	Nl	Thin-walled endothelial-lined spaces that are interspersed between strands of collagen	Biopsy	NA
Cavernous hemangioma	Idiopathic	–	–	Usually in third to fifth decades of life.	Painless, slowly progressive protrusion or bulging of their globe	–	–	Nl	–	–	–	Nl	Nl	Nl	Nl	Nl	Engorged vascular channels, which are tightly knit and separated by fibrous septae	Clinical manidestation	Diplopia Decreased color vision Visual field deficits
Diseases	Etiology	Congenital	Acquired	Demography	Appearance	Fever	Bleeding	BP	Hepatosplenomegaly	Lymphadenopathy	Other	WBC	Hb	Plt	LFT	ESR/CRP	Histopathology	Gold standard diagnosis	Associated findings

Symptoms

Cutaneous BA is characterized by the presence of lesions on or under the skin. Appearing in numbers from one to hundreds, these lesions may take several forms:

• papules or nodules which are red, globular and non-blanching, with a vascular appearance
• purplish nodules sufficiently similar to Kaposi's sarcoma that a biopsy may be required to verify which of the two it is
• a purplish lichenoid plaque
• a subcutaneous nodule which may have ulceration, similar to a bacterial abscess

While cutaneous BA is the most common form of BA, BA can also affect several other parts of the body, such as the brain, bone, bone marrow, lymph nodes, gastrointestinal tract, respiratory tract, spleen and liver.

Symptoms vary depending on which parts of the body are affected; for example, those whose livers are affected may have an enlarged liver and fever, while those with osseous BA will experience intense pain in the affected area.

Medical Therapy

Pharmacotherapy

BA responds dramatically to several antibiotics. Usually, erythromycin will cause the skin lesions to gradually fade away in the next four weeks, resulting in complete recovery. Doxycycline may also be used. However, if the infection does not respond to either of these, the medication is usually changed to tetracycline. If the infection is serious, then a bactericidal medication may be coupled with the antibiotics.

Bacillary angiomatosis

• Preferred regimen (1): Erythromycin 500 mg PO qid for 2 months at least
• Preferred regimen (2): Doxycycline 100 mg PO bid for 2 months at least

Prevention

If a cat is carrying Bartonella henselae, then it may not exhibit any symptoms. Cats may be bacteremic for weeks to years, but infection is more common in young cats. Transmission to humans is thought to occur via flea feces inoculated into a cat scratch or bite, and transmission between cats occurs only in the presence of fleas. Therefore, elimination and control of fleas in the cat's environment are key to prevention of infection in both cats and humans.

Related Chapters

• Cat scratch fever
• Trench fever
• Angiomatosis

References

• Gasquet S, Maurin M, Brouqui P, Lepidi H, Raoult D (1998). "Bacillary angiomatosis in immunocompromised patients". AIDS. 12 (14): 1793–803. PMID 9792380.CS1 maint: Multiple names: authors list (link)