Bacillary Angiomatosis and Bacillary Splenitis in Immunocompetent ...

Brief Report

Bacillary Angiomatosis and Bacillary Splenitis in Immunocompetent Adults Jordan W. Tappero, MD, MPH; Jane E. Koehler, MD; Timothy G. Berger, MD; Clay J. Cockerell, MD; Tzong-Hae Lee, PhD; Michael P. Busch, MD, PhD; Daniel P. Stites, MD; Janet Mohle-Boetani, MD; Arthur L. Reingold, MD; and Philip E. LeBoit, MD Annals of Internal Medicine. 1993;118:363-365. Bacillary angiomatosis and parenchymal bacillary peliosis are recently described vascular disorders associated with infection by Rochalimaea henselae and Rochalimaea quintana, which occur in patients with either human immunodeficiency virus (HIV) infection or druginduced immune suppression (1-5). In addition, R. henselae and R. quintana (also the agent of trench fever) are both members of the family Rickettsiaceae (1, 4, 5), and infections due to Rochalimaea species have been associated with exposure both to cats (2) and to arthropod vectors (1, 5). We describe five patients with cutaneous bacillary angiomatosis or bacillary splenitis without evidence of HIV infection who were determined to be immunocompetent after immunologic evaluation. In three patients with both cat and cat flea exposures, infection by R. henselae was confirmed by amplification and sequencing of 16S rDNA from an infected tissue specimen. Methods Four patients with characteristic vascular lesions of cutaneous bacillary angiomatosis (1, 3) were examined. Patient 2, who lacked vascular lesions, had a 2-week history of left-sided abdominal pain, shortness of breath, lowgrade fever, nausea, diarrhea, and weight loss of 3.5 kg. Results of laboratory studies included hematocrit, 0.21 (2 months before it had been 0.34); lactate dehydrogenase, 1170 U/L; total bilirubin, 53 /xmol/L (3.1 mg/dL); conjugated bilirubin, 24 /rniol/L (1.4 mg/dL); and mildly elevated hepatic transaminases and alkaline phosphatase. A computed axial tomography scan of the abdomen showed a normal liver and hypersplenism with a 4-cm2 area of focal low attenuation. The patient underwent emergency splenectomy for impending rupture. The 1100-g spleen From the University of California, San Francisco, California; the University of California, Berkeley, California; the University of Texas Southwestern Medical Center at Dallas, Texas; the Irwin Memorial Blood Centers, San Francisco, California; and the Centers for Disease Control, Atlanta, Georgia. For current author addresses, see end of text.

revealed a 4.5-cm3 mottled area consistent with infarction and two 0.6-cm3 tan nodules beneath the capsular surface. Results of routine bacterial cultures were negative. In June 1991, all five patients had blood drawn for HIV culture, serologic analysis, and polymerase chain reaction studies using techniques described previously (6, 7). In August 1991, all patients had blood drawn for immunologic evaluation, including quantitative immunoglobulins, complement, lymphocyte subset percentages, neutrophil oxidative burst (8, 9), T-lymphocyte activation studies to phytohemagglutinin, and B-lymphocyte activation studies to pokeweed mitogen (10, 11). After their blood was drawn, patients had skin test antigens to purified protein derivative, mumps, Trichophyton, and Candida albicans placed and read at 48 hours. The diagnosis of cutaneous bacillary angiomatosis was established using defined histopathologic criteria (3). Bacterial DNA present in the infected tissue specimen was extracted from either frozen skin biopsy tissue (Patient 4) or from sections of formalin-fixed, paraffin-embedded biopsy specimens (1, 12). Insufficient tissue was available from Patients 1 and 3. Extracted DNA was amplified by polymerase chain reaction using primers p24E and pl2B (1, 12). Control tissues were simultaneously extracted and amplified (1). Amplified 16S rDNA products from Patients 2, 4, and 5 were sequenced as described previously (1). Results Only Patient 2 had a well-documented antecedent chronic illness—hereditary spherocytosis and non-insulin-dependent diabetes mellitus—and no patient was receiving immunosuppressive drugs (Table 1). Idiopathic hemochromatosis was diagnosed concomitantly with bacillary angiomatosis in Patient 3. All patients responded to oral antimicrobial therapy of 4 to 6 weeks duration. Histologic examination of skin biopsy specimens from Patients 1, 3, 4, and 5 were diagnostic of bacillary angiomatosis; splenic tissue from Patient 2 showed necrotizing splenitis with fibromyxoid changes, degenerating neutrophils, and mononuclear cells in the absence of both vascular proliferation and granuloma formation. Specimens from all patients showed many bacilli on both Warthin-Starry staining and electron microscopic examination. Amplification of the DNA extracted from infected tissue from Patients 2, 4, and 5 produced a 16S rDNA fragment of approximately 300 base pairs. The amplified DNA fragment from tissue of Patients 2 and 4 is shown in Figure 1. The sequence of this 16S rDNA fragment from Patients 2, 4, and 5 was identical to that of R. henselae (4, 12).

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Table 1. Characteristics of Immunocompetent Patients with Bacillary Angiomatosis and Bacillary Splenitis Characteristic

Patient 2

Patient 1*

Age, y Geographic location (state) Animal exposures in the 6 months before symptoms Insect bite exposures in the 12 months before symptoms Underlying conditions

56 40 Maryland California Bird; multiple pecks Cat; no history and scratches of bite or scratch Mites, chiggers Cat fleas, chiggers

Temperature at diagnosis, °C Systemic symptoms and signs

37.0

Lesions (location) Date of disease onset Date of biopsy confirmation Human immunodeficiency virus laboratory studies^: Immunologic assessment§ CD4 cell count||, cells/mm3 Treatment (response)

None

Patient 4

Patient 3

Patient 5

41 74 Texas California/Texas Cat; multiple bites Cat; multiple bites and scratches and scratches

42 Texas Cat; multiple bites and scratches

Cat fleas, chiggers Cat fleas, mites

Cat fleast, fire ants

Hereditary Hemochromatosis spherocytosis, noninsulindependent diabetes mellitus 39.0 38.2

None

Undiagnosed arthralgias, and fatigue

38.5

37.5

Skin (arm) January 1987 June 1988

Abdominal pain, Chest pain, pleural splenomegaly effusions, hepatosplenomegaly Spleen Skin (nose) October 1990 September 1990 January 1991 February 1991

Neck stiffness, adenopathy, conjunctivitis Skin (neck) January 1991 February 1991

Cough, adenopathy, mild synovitis Skin (genital) April 1991 April 1991

Negative

Negative

Negative

Negative

Negative

Normal 1244 Minocycline (resolution)

Normal 1320 Erythromycin (intolerant), doxycycline (resolution)

Normal 960 Erythromycin (resolution)

None

Normal Normal 1188 635 Splenectomy, Trimethoprim-sulfamethoxazole erythromycin (none), erythro(resolution) mycin (resolution)

* Clinical presentation of Patient 1 described previously in Cockerell et al. Arch Dermatol. 1990;126:787-90. t Contact with cat with fleas but without definitive patient history for flea bites. $ Human immunodeficiency virus (HIV) types 1 and 2 serology, HIV-1 p24 antigen, cell cultures for HIV-1, and polymerase chain reaction studies for HIV-1 DNA. § Leukocyte subsets, lymphocyte activation to phytohemagglutinin and pokeweed mitogen, neutrophil oxidative burst, quantitative immunoglobulins, and complement assays (CH50, patients 1 to 5; and C3 and C4, patients 1, 3, and 5). Positive skin testing to mumps antigen (Patients 1 to 5); Trichophyton antigen (Patient 1). Negative skin testing to Trichophyton antigen (Patients 2 to 5); Candida albicans antigen (Patients 1 to 5); and purified protein derivative (Patients 1 to 5). || Absolute CD4 cell count reference range: 494 to 1362 cells/mm 3 (Patients 1, 3, and 5) and 424 to 1671 cells/mm 3 (Patients 2 and 4).

Discussion We evaluated four patients with cutaneous bacillary angiomatosis and one with bacillary splenitis and found no evidence of HIV infection using a combination of sensitive HIV antibody and antigen assays, as well as viral culture and polymerase chain reaction techniques. In addition, both cellular and humoral immunity were evaluated and no abnormality was found. Because host defense mechanisms against Rochalimaea species are not well understood, defects may have been undetected by our methods. Two patients had underlying illnesses thac may be associated with altered immune function, but no consistent immune defect has been associated with these conditions (13-15). The histopathologic findings were diagnostic for bacillary angiomatosis in all four patients with cutaneous disease; tissue from Patient 2 showed necrotizing splenitis with characteristic bacillary organisms (3, 12). Amplification and sequencing of rDNA from tissue of Patients 2, 4, and 5 confirmed that the infecting organism was R. I enselae. Although we cannot speciate the bacilli seen in abundance with the Warthin-Starry stains of Patients 1 and 3, the histopathologic changes met all criteria for the diagnosis of cutaneous bacillary angiomatosis (3), a disease associated with R. henselae and R. quintana (1). 364

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Bacillary splenitis in the absence of peliosis appears to be another manifestation of R. henselae infection. A clinical spectrum of R. henselae infection may exist, beginning with fever and bacteremia, progressing to bacillary splenitis and finally to bacillary peliosis. Differences in host immune function also may play a role in disease progression. The diagnosis of cutaneous bacillary angiomatosis and bacillary splenitis should be pursued in the immunocompetent patient when clinical or histopathologic features are suggestive. On the basis of these five patients, we recommend treatment with erythromycin or doxycycline for at least 6 weeks when the diagnosis is confirmed. Acknowledgments: The authors thank Drs. Gregory L. Rumore, Francis X. Burch, Merle W. Delmer, Joan King-Angel, Gail Plecash, and Carol E. Wratten for helping to obtain blood and tissue samples and for providing clinical information on Patients 2, 4, and 5. They also thank Lorrie Epling and Thomas McHugh for technical assistance. Grant Support: By a National Research Service Award (AR07175-15) and a Dermatology Foundation Research Fellowship (Dr. Tappero) and by the University of California, San Francisco (UCSF) AIDS Clinical Research Center and the John D. and Catherine T. MacArthur Foundation (Dr. Koehler). Requests for Reprints: Jordan W. Tappero, MD, MPH, Centers for Disease Control and Prevention, Mail Stop (C09), 1600 Clifton Road, NE, Atlanta, GA 30333.

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Dr. Reingold: Epidemiology Program, School of Public Health, University of California, Berkeley, Haviland Hall, Room 102, Berkeley, CA 94720. Dr. LeBoit: Department of Pathology, University of California, San Francisco, CA 94143-0506.

Figure 1. Amplification of rochalimaea DNA. DNA was extracted from formalin-fixed, paraffin-embedded, or frozen biopsy specimens from Patients 2 and 4, and amplified followed by electrophoresis on a 1.5% agarose gel and amplification. Lanes 1 and 8 contain DNA size standards. The DNA template added for each polymerase chain reaction tube: lane 2, Rochalimaea henselae-, lane 3, complete reaction mixture without DNA template; lane 4, DNA extracted from frozen skin biopsy tissue of Patient 4 when bacillary angiomatosis was diagnosed; lane 5, DNA from frozen skin biopsy of a Kaposi sarcoma lesion, extracted at the same time as the DNA in lane 4; lane 6, DNA extracted from formalin-fixed, paraffin-embedded splenic tissue of Patient 2 at the time of bacillary splenitis diagnosis; and lane 7, DNA from formalin-fixed, paraffin-embedded, control splenic tissue, extracted at the same time as the DNA in lane 6. A fragment of approximately 300 base pairs was amplified from R. henselae reference strain DNA and from the DNA extracted from both the frozen and paraffin-embedded tissue specimens of Patients 2 and 4. There was no similar amplification from the control tubes without added DNA, from the Kaposi sarcoma specimen, or from the control spleen specimen. Numbers at the right and left indicate the number of base pairs of the DNA standards. Current Author Addresses: Dr. Tappero: Centers for Disease Control and Prevention, NCID/DBMD, Mail Stop (C09), 1600 Clifton Road, NE, Atlanta, GA 30333. Dr. Koehler: Departments of Medicine and Laboratory Medicine, University of California, San Francisco, Box 1204, San Francisco, CA 94143-1204. Dr. Berger: Department of Dermatology, University of California, San Francisco, San Francisco General Hospital, Room 4M70, 1001 Potrero Avenue, San Francisco, CA 94110. Dr. Cockerell: Department of Pathology, University of Texas, SW, 5323 Harry Hines Boulevard, Dallas, TX 75235-9072. Drs. Lee and Busch: Irwin Memorial Blood Bank, 270 Masonic Avenue, San Francisco, CA 94118. Dr. Stites: Department of Laboratory Medicine, University of California, San Francisco, 500 Parnassus Avenue, Box 0134, San Francisco, CA 94143. Dr. Mohle-Boetani: Santa Clara County Health Department, Medical Services, 2220 Moorpark Avenue, San Jose, CA 95128.

References 1. Koehler JE, Quinn FD, Berger TG, LeBoit PE, Tappero JW. Isolation of Rochalimaea species from cutaneous and osseous lesions of bacillary angiomatosis. N Engl J Med. 1992;327:1625-31. 2. Tappero JW, Mohle-Boetani J C , Koehler JE, Swaminathan B, Berger TG, LeBoit PE, et al. The epidemiology of bacillary angiomatosis and bacillary peliosis. JAMA. 1993;[In press]. 3. LeBoit PE, Berger TG, Egbert BM, Yen TS, Stoler MH, Bonfiglio TA, et al. Epithelioid haemangioma-like vascular proliferation in AIDS: manifestation of cat scratch disease bacillus infection? Lancet. 1988;1:960-3. 4. Regnery RL, Anderson BE, Clarridge JE 3d, Rodriguez-Barradas MC, Jones DC, Carr JH. Characterization of a novel Rochalimaea species, R. henselae, sp. nov., isolated from blood of a febrile, human immunodeficiency virus-positive patient. J Clin Microbiol. 1992;30:265-74. 5. Welch DF, Pickett DA, Slater LN, Steigerwalt AG, Brenner DJ. Rochalimaea henselae, sp. nov., a cause of septicemia, bacillary angiomatosis, and parenchymal bacillary peliosis. J Clin Microbiol. 1992;30:275-80. 6. Busch MP, Eble BE, Khayam-Bashi H, Heilbron D, Murphy EL, Kwok S, et al. Evaluation of screened blood donations for human immunodeficiency virus type 1 infection by culture and DNA amplification of pooled cells. N Engl J Med. 1991;325:1-5. 7. Lee T-H, el-Amad Z, Reis M, Adams M, Donegan EA, O'Brien TR, et al. Absence of HIV-1 DNA in high-risk seronegative individuals using high-input polymerase chain reaction. AIDS. 1991;5:1201-7. 8. Epling CL, Stites DP, McHugh TM, Chong HO, Blackwood LL, Wara DW. Neutrophil function screening in patients with chronic granulomatous disease by a flow cytometric method. Cytometry. 1992;13:615-20. 9. Stevens P, Winston OJ, Van Dyke K. In vitro evaluation of opsonic and cellular granulocyte function by luminol-dependent chemiluminescence: utility in patients with severe neutropenia and cellular deficiency states. Infect Immun. 1978;22:41-51. 10. Stites DP. Clinical laboratory methods for detection of cellular immunity. In: Stites DP, Terr Al; eds. Basic and Clinical Immunology. 7th edition. East Norwalk, Connecticut: Appleton and Lange; 1991:263-83. 11. Maliush AE, Strong DM. Lymphocyte proliferation. In: Rose NR, Friedman H, Fahey JL; eds. Manual of Clinical Laboratory Immunology. 3d ed. Washington, DC: American Society for Microbiology; 1986:274-81. 12. Relman DA, Loutit JS, Schmidt TM, Falkow S, Tompkins LS. The agent of bacillary angiomatosis. An approach to the identification of uncultured pathogens. N Engl J Med. 1990;323:1573-80. 13. Tchorzewski H, /eman K, Baj Z, Pluzanska A, Chilarski A, Majewska E, et al. T Lymphocyte subsets, natural killer cell cytotoxicity and autologous mixed lymphocyte response in children after splenectomy because of hereditary spherocytosis. Exp Clin Immunogenet. 1989;6:185-9. 14. al-Kassab AS, Raziuddin S. Immune activation and T cell subset abnormalities in circulation of patients with recently diagnosed type 1 diabetes mellitus. Clin Exp Immunol. 1990;81:267-71. 15. De Sousa M. Review: Immune cell functions in iron overload. Clin Exp Immunol. 1989;75:1-6.

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